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Semaglutide — sold as Ozempic or Wegovy – offers nothing short of a revolution for changing body weight with a medication. With A-list celebrities racing to get their hands on them, these new treatments pose critical questions about the very nature of body weight, obesity, and their relationship to health. On the one hand, it and similar drugs offer a relatively safe, very effective way to drop body fat. On the other, to what end? Abdul sits down with Dr. Shauna Levy, an obesity medicine doctor, to talk about how semaglutide works, what it means for the patients she treats, and what it means for how we ought to think about body weight.

TRANSCRIPT

[music break]

Dr. Abdul El-Sayed, narrating: It’s been three years since the COVID 19 pandemic officially began in the U.S.. A blockbuster study suggesting masking is ineffective was ineffective. President Biden’s 2024 budget calls for $20 billion dollars for public health, bolstering Medicare and capping insulin prices across the board. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Today we’re talking about body weight. I know what you may be thinking. Abdul, didn’t we just do an episode about this a few months ago? It’s true. Back in January, I talked to Professor Harriet Brown, author of Body of Truth about weight stigma, and all the ways our obsession with weight can cause harm to individuals and society. But we’d always wanted that to be the first conversation. A broader discussion about body weight and obesity in the U.S. And since that conversation, well, that conversation has gotten a lot more pressing. And it all goes back to a new blockbuster medication you’ve almost definitely heard of by now. 

[clip of Ozempic commercial] Oh oh oh Ozempic. 

[clip of unspecified news reporter] What started as a common diabetes medication has now become the hot celebrity drug for weight loss and has now evolved into a full scale national trend. 

[clip of unidentified Ozempic user] I just start dropping pounds left and right. 

[clip of unspecified news reporter] The topic Ozempic has over 300 million views, with scores of users crediting the drug for their weight loss success. 

Dr. Abdul El-Sayed, narrating: Semaglutide, sold first under the trade name Ozempic as a treatment for diabetes and now Wegovy as a treatment for obesity has taken society by storm. It’s become the drug of choice for Hollywood elite, with rumors that nearly every A-lister in town is on it. Even for the rest of us, Semaglutide has been among the most sought after treatments in America. There were more than 1.2 million prescriptions filled for the drug this past December alone. One doctor told Slate magazine, quote, “not since Botox or Viagra has a drug like Ozempic come along that people instantaneously know and ask for by name.” So what is Semaglutide? Originally developed as a diabetes medication, its massive effect on weight loss was quickly recognized, prompting its manufacturer to remarket it for that purpose. The medication is what’s called a GLP-1 agonist. Agonists are compounds that mimic something the body already makes, in this case a hormone called GLP-1. It’s released by the small intestine when it’s full of food. That hormone works in our stomach. It tells it slow up, I’m already full and that makes sense. If the intestines are already full of food, you don’t want the stomach to keep dumping more in. It also acts in the pancreas to tell it to release more insulin, the body’s main hormone for sugar storage. That makes sense too, because if the gut is full of food. We’re going to need to start storing it, which requires insulin. But that’s only where it’s actions begin. The most powerful mechanism of action is what it does in our brains, the central processor of the whole operation. It literally tells us to stop eating, that we’re already full, even if we really aren’t. And that’s perhaps the most salient sensation that patients taking Semaglutide report. They just don’t feel the urge to eat. Their favorite foods just sound meh. Hence the dramatic weight loss. Semaglutide is the satiety medication that’s been the holy grail of pharmaceutical research in this space. And now it’s here and the consequences are staggering. In trials, patients on Semaglutide lost upwards of 12% of their body weight in just 28 weeks. To put that in perspective, a 200 lb. person would have lost about 24 lbs. in six months. That’s serious weight loss. In fact, it’s difficult to state just how impactful that level of weight loss can be. So rather than try, I reached out to some of you, our listeners, to ask you about your experience with Semaglutide. We got a lot of incredible responses, but I wanted to share this one from Dana with you now. I think her experience encapsulates exactly what this med can do for folks. 

[clip of Dana, AD listener] Let me start by saying I do not have type two diabetes, but I did have a precursor condition called insulin resistance. I also had high A1C and was overweight despite eating really great and exercising literally 2 hours every day. A year and a half ago. I just had had it. I was in tears. I went to my doctor and he suggested that I increase my workouts to 3 hours a day. How helpful was that? Long story short, I went to another doctor who suggested Wegovy. That’s the weight loss approved version of Ozempic. I was on that for about six months and when the shortages hit, I switched to Mounjaro, which is another GLP-1 agonist. These drugs have literally changed my life. I lost 37% of my body weight in just about a year. I feel great. And all of those medical conditions no longer affect me. 

Dr. Abdul El-Sayed, narrating: Clearly, Semaglutide is life changing for people like Dana, and that’s exactly what medications are supposed to do. No question about it. That’s a big deal. But there’s a deeper piece here I don’t want us to lose sight of. And that’s the fact that having quote “a drug for obesity” fundamentally changes the way we talk about it. If you’ve listened to the show for any length of time, first, thank you. But also, you know, I take real issue with the way we individualize many things in public health. Take COVID as an example. This was a society wide pandemic that we’ve now individualized. Wear a mask. Take your vaccine. Those are great things to do, no doubt. But they don’t change the central fact that the risk of getting COVID goes up for everyone when more people have COVID. There’s a societal component here we almost always either erase, willfully ignore or forget about in the first place. Body weight is similar. Eat right. Exercise. Great things to do. Sure. But individuals behaviors around those things don’t quite explain why the proportion of people meeting the obesity threshold for body mass index has tripled in the last half century. That has a lot more to do with the way our society has made doing those things that much harder. What we’re observing in individuals is probably more appropriately understood as a susceptibility to a fundamentally exploitative food environment and a society built around specifically limiting the amount of body movement we do to transport ourselves from point A to point B. Rather than walk to work, most of us commute with the company of a good podcast in an air conditioned automobile. Why have we built our society this way? Well, because there are huge corporations on the other end feeding us excess sugar or selling us those machines who make billions of dollars off of us. And they’ve captured enough influence over government to make sure it won’t do a damn thing about it. Enter Novo Nordisk, the corporation that’s about to make billions on Semaglutide. Now they get to sell us the solution to the problem the other corporations made billions out of creating and on and on. By the way, that treatment, it’s $15,000 a year. Now consider the fact that body weight is substantially higher among the poor. You know, folks who can’t afford $15,000 a pop for medications. Putting the, quote, “solution to obesity” behind a $15,000 paywall will only further those inequities. But in case you thought that was all. There’s another wrinkle in the Semaglutide story, as I said at the top, Semaglutide was originally developed as a diabetes treatment marketed as Ozempic, the name you’re most familiar with. After the discovery of its weight loss results, Novo Nordisk repositioned the drug as Wegovy, targeting its weight loss patients. Where it’s now become most popular. Wegovy and Ozempic are of course the exact same drug and the secondary marketing for weight loss by the manufacturer without producing more drug created a nationwide shortage. That shortage is prompting questions about equity. Who deserves first access to the medication? Diabetes patients or weight loss patients or someone else? In fact, when we reached out to you about your experiences with Semaglutide, we got a lot of submissions about people who haven’t been able to access the drug for a variety of conditions beyond weight loss. Here’s a message from one of our listeners who has polycystic ovary syndrome or PCOS. 

[unnamed AD listener] I just started Wegovy, which is Semaglutide. It’s exactly the same as Ozempic. It just is given in different doses. I have been trying to get on it for about a year through my insurance. I have insulin resistant PCOS, which is extremely hard to get any type of medical treatment for. So it’s extremely, extremely frustrating seeing people on this medication that don’t necessarily need it because it took me so long to even be taken seriously. And I hope it works for me. It might not, but it’s more about my health instead of just esthetics and weight. Also, once it was finally approved for me, it was backordered and took me a while to get. 

Dr. Abdul El-Sayed, narrating: She’s one of hundreds of thousands of people affected by the shortage, but her plight and that of so many others forces us to ask a secondary question over who should and shouldn’t get access. Surely we probably all agree that when an A-list celebrity uses this medication to shed a few extra pounds, that folks like our listener and so many others deserve access to the medication first. Not to mention the message it sends to so many people out there about the lengths that they should go to to attain nearly impossible weight standards that further the stigma over body weight in the first place. But then what about someone who stands to lose 50 lbs. or 100 lbs? What if that person doesn’t yet have diabetes but is on the cusp? In no way was our listener doing this, but I worry that arguing that someone using this med for weight loss shouldn’t get the medication over someone with an illness like diabetes could inadvertently reinforce the stigma of obesity. In effect, suggesting that people using this medication for weight loss are just buying themselves out of the healthy eating and exercise they’re too lazy to do. What’s clear is that this new blockbuster drug is also a game changer for the way we think about, treat and even propose public health solutions for body weight. So today I wanted to talk about all of this, the shortage, the way we’re thinking about weight loss, how this drug works with someone who spends more of her time on all this. Dr. Shauna Levy is a surgeon who treats obesity. Here’s my conversation with Dr. Shawna Levy. 

Dr. Abdul El-Sayed: Okay. Can you introduce yourself for the tape? 

Dr. Shauna Levy: Yeah. I’m Shauna Levy. I am a bariatric surgeon and medical weight loss doctor. 

Dr. Abdul El-Sayed: So why did you go into obesity medicine? 

Dr. Shauna Levy: Well, so originally, you know, I am a bariatric surgeon, and so I, I want to say that I struggled with my weight, but I’ve come to the realization that I don’t know if I was that big growing up. I just heard a lot of people talking about me. So I always have had this idea that I was a big person and probably some body dysmorphia. So when it came time to decide what I want to do, I was very fascinated by weight loss and how it worked and bariatric surgery was really the first time that I understood there was a treatment for this disease other than diet and exercise, which had, I’d always heard my whole life going into the avenue of weight loss medicine has been a little bit more recent for me, and it was really with the introduction of GLP-1 agonists as a way to finally treat this disease in a different way that attracted me to obesity medicine as an extension of my bariatric surgery career. 

Dr. Abdul El-Sayed: There is so much around how we um treat uh this condition, you know, that you can do. And um so much of our conversation today is about what happens when, you know, when when we find a new treatment and how to think about that. I want to sort of step back and we’re going to get to um Semaglutide and um and the ability to to treat the condition safely and effectively. But I want to ask you, you know, how do you think about the ideology of obesity? Is this a natural response to a twisted environment, or is it something about a physiology um that is itself off? How do you think about that? 

Dr. Shauna Levy: Well, I don’t think they’re mutually exclusive. I think they’re both pieces of the puzzle. You know, our bodies are designed for survival, right. The survival of the fittest. We’ve been hearing that forever. And part of survival is being able to hold on to energy. And, you know, our bodies have not evolved as much as we would have liked since the hunter and gatherer times that weren’t that long ago. And it was to our survival advantage to be able to hold on to calories and our genetic advantage. And during times of scarcity, that’s what’s helpful to us. But fast forward till now, and food is not scarce and food is relatively calorie dense, but our body thinks we’re still in that survival mode. So it wants to hold on to as many calories as we can. And we’re not working in the fields anymore and we’re not really moving anymore. And just all these contributing factors have led to, I guess, the place we are now, where obesity is the second leading cause of preventable death. 

Dr. Abdul El-Sayed: Mmm. You know, we’re in this uh moment where we um are dealing with the fact that our physiology cannot and has not evolved as fast as the technology behind food production at scale, specifically around food that is intended to exploit our physiology and its failure to catch up. And, you know, it’s it it it leads to a set of challenges. Now, you know, I had a previous conversation with a professor named Harriet Brown, um and she thinks a bit about the condition of obesity, not much as a disease, but as um sort of the collective consequence of this imbalance. And she’d argue that, you know, we’re dealing with a j-shaped curve here, one where um there is not a clear linear relationship between, you know, extra pounds or fat tissue or BMI uh and um all cause mortality or specific cause mortality, but that there is a sweet spot, there’s an ideal spot to be at. Um. And I think in some respects I don’t want to speak for her, but I think she might push and say part of the problem with the way that we think about and conceptualize this condition um is that we don’t think very clearly in j-shaped curves. We think in linear terms. So if a lot is bad, then a little bit is is bad too. When when in fact maybe that’s not quite the case or what the evidence suggests to us. Um. As you think about the patients that you see in front of you, how do you contend with that individual in front of you? And then the collective challenge um around the conversation that we have about body weight, about about fat mass, um and how do you advise your patients about how to think about those things? 

Dr. Shauna Levy: That’s a lot of, [laugh] a lot of topics there. Um. So, you know, of course, I have to treat each patient in front of me as an individual cause as they are, and they have different problems. I mean, the advantage I have is that I am treating obesity and treating, you know, health. And so somebody who’s come to me is uncomfortable with the position they’re at, whether that be from like mass, sheer mass, meaning they have knee pain, hip pain, back pain um from the size that they are, or they have metabolic problems like kidney disease or high blood pressure or diabetes that they want to treat. And so they’re coming to me because they’re asking for a treatment. Um. And so I look at them, I look what weight they have, I look what comorbidities they’re also suffering from and then try to determine what is the best treatment option for them. Of course, it’s not one size fits all. And this is, I think a little bit also where people struggle is they think I’m saying diet and exercise or medicine, diet and exercise or surgery, medicine or surgery when it’s really a combination of all of those things um to help somebody get to a healthier place, because ultimately that’s what it’s about, right? Being in a healthier place than you are now, it’s not really about one specific weight. It’s just about being in a healthier host. 

Dr. Abdul El-Sayed: Semaglutide is an interesting drug because it leverages its um its actions against appetite and um and in some respects uh really takes on the central mismatch that we’ve identified between our um laggard evolution and our um hyper intense, you know, capitalism driven food environment. And so I’d love I’d love to hear a bit more about how it works um and what it does and um what its what its effects have been? 

Dr. Shauna Levy: Okay so Semaglutide, which has the branded name Ozempic for people with diabetes and Wegovy for um people with obesity, uh it is a glucagon-like-peptide-1, GLP-1 receptor agonist. I normally just say GLP-1 uh receptor agonist and so GLP-1 is a naturally occurring hormone in our body. It’s released when we ingest carbohydrates, it leads to the end of a meal. So it promotes fullness and decreases hunger, which normally in our body, again, when we’re eating something, it would encourage us to stop eating. And normally it’s very short lived in the body, um but this medication augments already what’s occurring in our body. So it again leads to decreased feelings of hunger and increased feelings of fullness, which are really separate things. It also helps us regulate our glucose metabolism, but it is glucose dependent. So what that means is it’s not going to lead to low blood sugar like other diabetes medications might. Um. And so it’s really helpful in that way. And that’s why it can be used as an obesity medication in people without diabetes. 

Dr. Abdul El-Sayed: So it moderates our um satiety and our hunger. And then it um it basically helps our bodies recognize when glucose is on board better. 

Dr. Shauna Levy: Yes. And stimulates our body to release insulin. 

Dr. Abdul El-Sayed: Okay. 

Dr. Shauna Levy: Or really respond to insulin. And that’s what it does, you know, by definition. But in practical terms, in talking to my patients, it really helps quiet like the food chatter. And what I mean by that is the the voices that you may hear in the back of your head that say, like, eat this thing, you know, I want a little bit more. Some people without the disease of obesity might be able to ignore those. But to a certain level, those messaging inside your brain cannot be ignored. And this medicine helps to quiet that, like you said, to live in this world where we have way too many foods that are so calorie dense um that we don’t know what to do with, and we can exist easier in that world if there’s not always a voice in the back of our head saying, ooh, that looks good. Let me have a bite of that Pop-Tart or whatever it may be. 

Dr. Abdul El-Sayed: We’ll be back with more with Dr. Shauna Levy after this break. [music break]. 

[AD BREAK]

Dr. Abdul El-Sayed: Just how much weight loss um do patients experience uh in studies of semaglutide? 

Dr. Shauna Levy: So. It’s almost 90%. It was like 87% of patients lost at least 5% of their total body weight, which is huge to have that many patients lose weight. Over 50% of patients lost somewhere between 15 and 18% of their total body weight, which is an enormous amount. Normally studies that look at just diet and exercise alone, they can see patients losing up to nine-ish percent total body weight. But really, after about a year, it goes down to about 4% total body weight loss. And these the weight loss was sustained because they they did studies where they took the patients off the medicine and compared them to the patients who were still on the medicine and the majority of patients still on the medicine kept their weight off as opposed to the patients who uh went off the medicine had weight gain. 

Dr. Abdul El-Sayed: Okay. So this is the kind of thing kind of like a hypertension medication or a cholesterol medication, which is going to be um consistent use to sustain the outcomes. 

Dr. Shauna Levy: Correct. As long as it’s working for you, you should take it. 

Dr. Abdul El-Sayed: What are some of the side effects uh that that that people on the medications experienced? 

Dr. Shauna Levy: So the side effects. Most patients experienced some gastrointestinal side effects, but very minor like nausea. And I see that a lot of my patients, especially when they’re up dosing the medication. So you have to start the medication at a low dose and work your way up to the maximum so that your body can get adjusted to the medication. And most people experience some nausea, maybe some vomiting when they’re about 24 to 48 hours after they give themself the dose. And especially each time they go up on a dose. Um. I think it was something like 60% of patients in this study had some sort of gastrointestinal side effect, but only a very small amount, like three to 4% actually stopped using the medicine because of the side effects. So my point is, yes, they had some side effects, but they were very minor, not enough to make them want to stop using it. 

Dr. Abdul El-Sayed: And how does this compare to what was the gold standard um for for treating, you know, very serious obesity, which was bariatric surgery. Um. How does that compare in terms of just the efficacy, in terms of the side effect profile? 

Dr. Shauna Levy: Yeah. So before GLP-1 receptor agonists, the best medication on the market was a stimulant, and that really leads to about 4 to 5% total body weight loss. And honestly, people felt pretty crummy having to take it because it’s a stimulant, you know, So their heart may be racing, they may have a headache, they can’t sleep, you know, a lot more if they have a heart condition, you know, make them at risk for some sort of cardiac event um and so that it’s still in use, but patients just don’t feel nearly as good. Um. Liraglutide, also known as Saxenda, is a much better weight loss injectable, but it’s also a GLP-1 receptor agonist. So that’s how we really understood that and some of the other medications that before that we really understood that this category of medication was a game changer. 

Dr. Abdul El-Sayed: And how does this compare to bariatric surgery in terms of outcome profile? 

Dr. Shauna Levy: So there’s medications coming in the future that are going to rival bariatric surgery. But for what exists right now, we know that bariatric surgery, it’s a little bit confusing because in bariatric surgery we talk about excess body weight as opposed to total body weight loss. So it’s hard to compare, but total body weight loss for bariatric surgery, it’s usually closer to 30 to 50% um as opposed to the 15 to 18%. So there’s definitely more weight loss. But like I said, in the coming years, there is medication that they’re saying could lead to 40% total body weight loss so absolutely rivaling bariatric surgery. And again, like I mentioned before, a lot of people think it’s one or the other, but sometimes it’s both. Sometimes you need to have both to treat the disease. 

Dr. Abdul El-Sayed: Is that just a selection effect? I would imagine, you know, the upfront cost and not just not just um uh financial, but just the the willingness to go under the knife would only really be tolerable in a situation where you had um you know very, very, very extensive excess fat tissue and that, you know, the excess body weight loss that you’re seeing in bariatric surgery may just be a function of, of how much there is to lose relative to uh the medication use. And I guess what I’m getting at here is, is the threshold at which someone might consider uh treatment with Semaglutide just lower than it might be for bariatric surgery? 

Dr. Shauna Levy: I think what you’re asking me is how does somebody decide what treatment they want to pursue um in terms of medicine or surgery or both? A lot of it is access to care honestly. Insurance is a huge barrier to access for medication or surgery. So that’s issue number one. Whether or not they have coverage, they may come in wanting medicine and only have coverage for surgery. They may come in wanting surgery and only have coverage for medicine. Option two is a lot less frequent. But um that’s part of the equation, of course, what they qualify for, so they may want surgery, but where their body mass index is because like it or not, like that’s what insurance uses to qualify somebody for intervention. Um. Their body mass index may be too low to qualify for surgery. Uh. Usually, obviously, it’s not too high to qualify for anything. 

Dr. Abdul El-Sayed: You know, the the the barrier of insurance is one where you and I are going to agree. Um. But it does it does set up a pretty big equity challenge, which is to say we know that the rate of excess body fat is substantially higher among lower income folks and because of structural racism, higher among people of color. And these are also the folks who are probably least likely to be able to afford these medications. Um. Right now, a course of Semaglutide for a year is going to be about $15,000 a pop. And that’s, you know, prohibitive out-of-pocket. How should we think about the way that this is going to uh potentially exacerbate uh inequalities in excess body fat? 

Dr. Shauna Levy: I think it’s an enormous challenge and one that I feel very passionately about fighting, because this is a deadly disease and it’s just getting worse. And like you said, the structural racism that exists in our country has made you know the disease of obesity worse in in these areas. And more like like, for instance, Louisiana. Exactly where I live. Right. The rate of obesity is about 40% of the state. And it’s one of the least insured states in the country. And people cannot afford to pay out of pocket what, maybe they can afford for a couple of months, but certainly not for the rest of your life if you’re looking for a long term treatment. And so it’s not an option. And so they’re forced to choose other routes. Now, Medicaid in this state will cover surgery. So that can be an option for some people and so does Medicare. But, you know, it’s just a huge challenge this access to care for most patients and the underinsured are probably the biggest gap, honestly. Uh because so obesity is not considered an essential health benefit in the Affordable Care Act. So states can determine whether or not they want to include obesity care. And most states have opted out of coverage. And so people who go through um Affordable Care Act to get their insurance don’t have an option for obesity care, whether that be medicine or surgery. 

Dr. Abdul El-Sayed: And I want to ask you, um you know, one of the challenges that that comes up, right is um stigma among folks uh with excess body fat. And the worry is that we’re already starting to see, you know, a couple of things happen. The first is you’re starting to see folks who weren’t all that um out of post to begin with, uh whether they be A-list celebrities or others on social media using this um to get even thinner, um which does a couple of things. It changes the ideal body image, um then by definition, holding other folks accountable to it. But then it also, you know, opens up for the same kind of um, I’d say, misuse of this kind of medication. Um. How have we thought about the misuse of of this medication and the implications that it has for uh body image and the stigma that then comes with that? 

Dr. Shauna Levy: I mean, obviously, this is a huge issue because, number one, there’s no access to care issue for people who can pay for whatever they want. And so so they can pay. You know, I, I worry about doctors who will write for anything and don’t consider guidelines. And um the best, you know, the data to guide their management. But we know there are plenty of physicians out there, particularly in these wealthy environments, that are willing to do that. And it’s a concern. You know, it’s like you said, creating this unhealthy goal um in society for people. Beyond that, I don’t really think about it too much personally um because, again, to me it highlights just a lack of access for people to get these medications. And it it makes them desperate for medication in multiple ways. One, because maybe they want thinness, but also they want that advantage, right, to not feel so hungry all the time. And now that they know that this medication exists because of the popularity and just the everybody’s talking about it, they want to feel that too. But the people that are really winning honestly, right now are these like medi spa’s and these clinics that are selling compounded semaglutide, which isn’t even the real thing. And I think that’s really a danger to people because they think, okay, my insurance isn’t going to pay for it, I’m not going to go to a doctor, but here I can go to this medi spa or whatever it is that’s written by possibly a non medical provider and get it and take it myself and it’s cheap and I can get it and yay I have it. I mean, that’s where a real problem exists. I think that people can potentially get very hurt and have major side effects. 

Dr. Abdul El-Sayed: Mm. What has it meant um that there’s been such a rush on this medication for um people that you’re trying to treat? Uh I can imagine there are probably folks who get the script whose insurance will cover it but then can’t actually find it. 

Dr. Shauna Levy: So. Yes, this was a huge problem when Wegovy came out, when they first came out, they almost immediately went into a shortage uh because they had manufacturing issues and nobody was really talking about it at that time. Outside, I mean, I didn’t hear a lot of it in the media, um but it was a huge issue because we finally had this great once a week easy to give medication, but we couldn’t get it. And so that’s of course, why people were leaning a lot harder on Ozempic and Saxenda which is another medication. So that was really hard for a while. Now that Wegovy’s back. It’s a lot easier. Um. The Ozempic shortage has been hard too, you know, people have been calling around to get their medication, but thankfully, starting in March, I think the shortages are all going to be lifted, which is great. I mean, people are frustrated, Of course. They want to treat their disease. They want to get help. I think the thing that’s unfair, though, is the way that media outlets and people in general have been framing people with obesity as a reason for the Ozempic shortage. I think that comes across to me as discrimination against obesity because the shortage is they didn’t anticipate the demand. Right. There’s so many people in this over half this country could benefit from those medication. They didn’t anticipate the demand. They didn’t make enough. They had supply chain issues. But sort of the only community that seems to be getting blamed for this is people with the disease of obesity. And that’s, I think, one of the biggest issues with that. 

Dr. Abdul El-Sayed: Yeah, I appreciate the point. And I guess one of the uh main sources of of pushback that I often have in a conversation about obesity is that for so long we’ve sort of thought about obesity as an individualized thing. And so in the past it was if you store a lot of adipose tissue, it must be that you’re too lazy to eat right or workout. And that is a personal failure. And I wonder now in in the world where treatment is so much more attainable through these medications that now it’s you know, you don’t even uh you don’t eat right, you don’t exercise and you’re not even willing to take your meds. [laugh]. 

Dr. Shauna Levy: Right. 

Dr. Abdul El-Sayed: And I’m wondering how uh you think about that and um you know what what you think this might do to exactly that question of discrimination against people who store uh excess adipose tissue? 

Dr. Shauna Levy: I think one of the best things that come from these medications is all these conversations and more people thinking about this disease and talking about this disease and wondering about this disease. People who have this disease finally feeling like, oh, maybe I haven’t been lazy all this whole time. Maybe I actually have been trying. And it’s my hormones that are fighting against me, which I think is so great to see when somebody comes to my office and I explain to them that this is actually a disease and all of those things they’ve heard about themselves their whole life are not true. There’s always tears. And so I think it’s really wonderful to give people relief to help them with something that they’ve struggled with their whole life. I just I love the conversations that are being had, and the realizations that maybe diet and exercise hasn’t been the sole treatment. You know, a lot of people are labeled as lazy when they do try hard, but also they may have two jobs and three kids. And, you know, to make it all work is just really hard. I think we would not obviously have nearly as much as obesity if we all worked outside and we had time to cook the right meals. But unfortunately, we live in the world that we live in. And so whether or not that makes us lazy people, I don’t know. But we want to survive. We know that and live longer and be healthier. And so if that means not being able to work out and not being able to be healthy but take a medicine to live longer, I mean, that’s something I’d be willing to do. Maybe not everyone. That’s my strategy. 

Dr. Abdul El-Sayed: Yeah, I appreciate the the point that you make about decoupling one’s uh motivations or grit uh or discipline from a physiologic process happening inside them. And I can appreciate how that itself can um can help to alleviate some of the consequences of stigma um in someone’s mind. And at the same time, you know, I can’t help but think about the broader societal consequence uh around this, because in so many ways, you’re right. We live in the world that we live in, and in that world we have, um you know, subsidized uh corn and corn products in a profound way. We’ve made uh cheap, unhealthy food far more accessible than uh healthier alternatives. We’ve normalized a, a system of transit that um leaves us without, you know, the regular walks that we used to take to try and get to the things that we needed to get to. Um. And I worry also in part that um, you know, if we know that the pathology is not really inside of us, but more outside of us in the society in which we are living, then this in some respects leaves us creating a manmade solution to a manmade set of problems. And rather than treating the pathology outside of us, um we are treating the physiological reaction uh to the pathology outside of us. And I’d love to get your reaction to that issue and whether or not, you know, in some respects, this like frees up a lot of the agency that um, frankly, government and uh and society at large should take in taking this problem on. 

Dr. Shauna Levy: I actually couldn’t agree with you more. I think that there are huge issues. The one that you didn’t mention that drives me bananas is marketing. And the fact that every single box is is a lie and a scam. I mean, honestly, even some of the quote, “health foods” are just trying to get you to buy something and say all the right things and trick people and it’s offensive. [laughing] Honestly, I mean, there’s a lot of problems with the way that we consume food, the way that we’re told about food. And we would benefit immensely if there were some sort of overhaul in regulatory bodies of how food is produced and how it’s consumed and how it’s advertised. Um. But you’re right. I mean, the easier solution is just to make a medicine to treat it. And that’s what they’ve done. Hopefully we can find a place where we can do both things like it doesn’t have to be mutually exclusive, that we have the medicine, we can’t also strive to be in a healthier place where we walk places and do things and actually have time during the day to make a healthy choice or have some activity. I mean, that would be perfect. 

Dr. Abdul El-Sayed: Well, I think we’ve uh we found a place of relative agreement here [laugh] um uh to end it. I really appreciate you coming on to educate us about this medication and uh to offer a perspective on um how we ought to think about obesity and adiposity and what these treatments mean for your patients and for millions of people around this country. Our guest today was Dr. Shauna Levy, she is a bariatric surgeon and obesity medicine physician. Uh. Dr. Levy, thank you so much for taking the time to join us today. 

Dr. Shauna Levy: Thank you so much for having me. Appreciate it. [music break]

Dr. Abdul El-Sayed, narrating: As usual, here’s what I’m watching right now. I can’t believe it, but it’s been three years of COVID-19. Three long years. Look, I’m super thankful COVID deaths have slowed over the past year, but even slowing means that a quarter of a million people died in that period. Overall, over the past three years, there have been an average of more than a thousand people who died every single day of this disease. That doesn’t include all the people who live their lives with human sized holes in their hearts. It doesn’t include all the economic upheaval that we’re still feeling today. Inflation, that was the pandemic. Interest rates rising to address inflation. Also because of the pandemic. I raised this because there’s been an effort from across the political spectrum to quote, “move on”. And don’t get me wrong. As you all know, I’m pragmatic about this. It doesn’t do any of us any good to pretend like the breathless pace of the first six months of the pandemic or the onset of Omicron ought to persist. That kind of alarmism is a great way to make sure that the vast majority of serious people just ignore you. But it doesn’t do us any good to pretend that this pandemic is behind us, or worse, that the quote “cure” was worse than the disease. That’s just bullshit designed to destroy public trust in government and public health. Instead, what I’m asking for no pleading for is an honest assessment of not just what went wrong, but what needs to go right next time. That starts with those of us who spend our days working in government public health. But it also includes political leaders on both sides of the aisle, thinking through what we need to learn about how we invest in public health over the long run. Because need I remind you again? Though this may be the worst pandemic in our lifetimes. It may not be the last. Toward that end, one of the least helpful studies I’ve ever read was published a few weeks back. But first, some context. In medicine and public health we’re a bit extra. When studies are done, we don’t just assume that one or two studies is the end of it. No we take all the studies and do studies of studies. That’s right. Studies of studies. We do this so that the best possible data rises to the top. That study of studies is called a meta analysis. One of the gold standards of meta analysis is what’s called a Cochrane review. So we thought that when there was going to be a Cochrane review of masking as a tool for respiratory viral prevention, that it would be a good study of studies. I guess not. Look, before I go on, it’s not that I take issue with the results. In science, you can’t argue with results. You can only argue with methods and whether or not methods were followed. And the issue with the study is that the methods were well there’s really no way around it, they were just shit. The study was entitled, quote, “Physical Interventions to Interrupt or Reduce the Spread of respiratory viruses.” The problem starts there. That’s not the way the study was interpreted or pitched. It was interpreted as a study about masks for COVID prevention. In fact, of the 12 studies that were included in the review on masking, only a handful were done during the pandemic. Most looked at the transmission of flu in non-pandemic conditions. The second issue here is that the intervention in the studies they looked at wasn’t actually mask wearing, but encouragement to wear masks. What exactly is encouragement? How does one standardize that? To appreciate the issue here. Let’s compare two studies they included in their review. One was a study of flu in college students in residence halls over the winter of 2007 and 2008, who were randomized to receive free masks in their dormitory mailbox and asked to wear them 6 hours a day. Another in Bangladesh during the pandemic, randomized whole villages to receive, quote, “promotion strategies”, including free masks and information on the importance of masks and compared COVID between the villages. Flu and college kids in the U.S. in 2008 versus COVID in Bangladeshi villages. In what world can you combine these studies and think you’re studying the same thing? But none of these issues stop the lead researcher one Professor Tom Jefferson, embarrassingly an epidemiologist at my alma mater in Oxford, to conclude that, quote, “There is just no evidence that they, meaning masks in this case, make any difference.” And that’s how the popular press has covered the review. The Cochrane collaboration, for their part, was so alarmed that they issued a clarification, quote, “The review is not able to address the question of whether mask wearing itself reduces people’s risk of contracting or spreading respiratory viruses.” Uh. So why did you do the study? The fact remains that the Cochrane study suffered from the most fundamental error in all of science, asking an imprecise or unanswerable question. It’s plausible that the investigators in any one of the 12 studies they used in their analysis were specific about the way they measured encouragement. But across the 12 studies, impossible. And that means that they were comparing apples to oranges within their own study of studies. As if that wasn’t bad enough, they then proceeded to make the second most fundamental error, overinterpreting the results to say something they couldn’t in fact say. I really wish they didn’t say anything at all because, well, poor communication has been a hallmark of the pandemic. This was a perfect example. Maybe somebody should do a study of studies on that. Finally, President Biden released his 2024 budget last week. Before I go on, this budget is dead on arrival because well we have a Republican House. That said, it can be taken as an outline of what President Biden would likely run on in 2024. And it’s jam packed with health proposals, though it says nothing about the ongoing pandemic, it proposes $20 billion dollars over five years to, dare I say, shore up the public health infrastructure. It would invest in the administration for strategic preparedness and response, the CDC, the NIH, and the FDA allowing them to update laboratories, enhance disease surveillance and improve state and local public health capacity and coordination. It also invests $10 billion dollars in Biden’s cancer moonshot. It doesn’t stop there. Beyond a $35 cap on insulin for seniors on Medicare, it proposes a cap on insulin for everyone. It would make the ACA expansions to provide health insurance for low income folks in communities that didn’t expand Medicaid permanent. Finally, it would shore up Medicare, paid for by expanding taxes on the highest income households. Why stop at Medicare as it is? How about Medicare for All? Again, none of this is going to pass muster with the GOP House. But it doesn’t mean that it couldn’t become law someday. Remember, folks, elections have consequences, make sure to go out and vote. Our votes choose our leaders. And the more we demand of them, the more they’re forced to take heed. That’s it for today. On your way out. Don’t forget to rate and review. It really does go a long way. Like seriously, please rate and review the show. I really hope you will. Also, if you love the show and want to rep us, hope you’ll drop by the Crooked store for some American Dissected merch. Logo mugs, T-shirts, science always wins sweatshirts and dad caps. All are available. [music break] America Dissected is a product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illic-Frank. Vasilis Fotopolous mixes and masters the show. Production support from Ari Schwartz and Ines Maza. Friday was Ines’s last day and we’re grateful for all of her insight and contributions. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sara Geismer, Sandy Girard, Michael Martinez and me. Dr. Abdul El-Sayed, your host. Thanks for listening. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.