Did you know that more than a third of people
in the United States meet the criteria for being obese?
That's over 60 million people.
And if you have a mental or physical condition
where you take medication that causes weight gain,
it's easy for you to gain enough weight
to be clinically obese.
Fortunately, there's a new wave of medication options
to help with this problem.
I'm Dr. Tracey Marks, a psychiatrist,
and I make mental health education videos.
There's been a lot of buzz lately
around the drug Ozempic
because it's been very popular for people to take
and drop 30 to 40 pounds pretty fast.
The drug is approved to treat diabetes
and because it works so well for weight loss,
it's been in short supply because of the demand.
This has made some people angry
saying that people who need it most aren't getting it
because of all these other people
who are taking it for vanity reasons.
Well, yes and no.
As of 2013, obesity has been classified
as a medical disorder
because it causes lots of other medical complications.
The term is used pejoratively
and there's a lot of shame around body size.
And until recently, helping someone lose weight
was just saying eat less and exercise more.
But this isn't the real answer
because weight gain is complicated.
How do you know if you are obese
and should pursue medical help to lose weight?
One method used to define obesity
is having a body mass index equal to or greater than 30
and commonly called a BMI of 30.
There are lots of online calculators to measure BMI
but the formula is your weight in pounds or kilograms
times 703 divided by your height
in either inches or meters
times your height again
in inches or meters or height squared.
But know this, it's not that hard to be obese.
For example, the average height
of an American woman is five foot four inches.
If that woman weighs 174 pounds or more, she's obese.
A six-foot-tall man only needs to weigh
221 pounds to be obese.
Now, there are limitations to this measurement
as it does not take into account ethnic groups
who may have more muscle mass.
Where I come from, we call that being thick or big-boned
but BMI is still a general measure of health nonetheless.
What's this got to do with mental health?
Many people with mental health disorders
are overweight or obese.
Some of the disorders like depression and insomnia
can cause weight gain all by themselves
in the absence of taking medications.
Having a history of trauma
triggers a stress response in your body
making you more vulnerable to gaining weight
through hormonal changes
that affect your appetite
and increase the risk of disordered eating
and it also increases fat storage.
Then, the medications that we use
to treat mental health disorders
notoriously cause weight gain.
The biggest offenders are the atypical antipsychotics
and then second in line would be the antidepressants.
The usual way they cause weight gain
is by increasing your appetite for carbohydrates.
The antipsychotic medications
can alter how you process glucose,
leading to insulin resistance.
Signs of insulin resistance
are developing fat around your midsection
and feeling hungry all the time.
I've had some patients tell me their growling stomach
keeps them awake unless they eat something before bed.
And of course, they don't eat broccoli.
They have a bowl of cereal.
So with obesity becoming a defined disorder
and not just a lifestyle or vanity issue,
anti-obesity medications have become legitimized
and more of them are coming to market in recent years
and they keep getting better and better.
One of the earliest medications was the drug fen-phen.
It was a combination
of the stimulant phentermine and fenfluramine
which is used to treat seizures.
It worked by reducing your appetite.
It was pulled from the market in 1997
because of serious lung and heart complications.
I was in my residency training at that time
and it did leave a negative impression with me
about using drugs to treat weight.
I mention this because even with the newer medications,
many doctors are reluctant
to prescribe them for various reasons
including fear of long-term effects.
Other medications that have been used
for medical weight loss are Contrave
which is a combination of naltrexone and bupropion.
And then, there's metformin, a diabetes drug.
I think both of these medications cost modest weight loss
with modest being 5 to 10% of your body weight.
5 to 10% is something
but it's not that much.
Let's go back to the woman who's five-foot tall
and weighs 180 pounds.
If she loses 10%, which is a lot for these older drugs,
she loses 18 pounds.
She's now 162 pounds,
which reduces her BMI to 28,
which is no longer obese,
but it's still on the high end of overweight.
Now we have a new generation of medications
that cause weight loss.
They work by reducing your appetite and slowing the rate
at which your stomach becomes empty after you eat.
This helps you feel full longer.
They also increase insulin secretion,
which is how they started as diabetes medications,
but that's not all.
They also stimulate brown fat,
which you can think of as padding
that we have in our bodies to help us stay warm.
Hibernating animals have a lot of it.
You don't see it in the form of love handles.
That's white fat tissue.
Brown fat is located internally
around your neck, chest, and kidneys.
When brown fat gets activated,
it burns white fat for fuel,
so these drugs indirectly cause body fat loss
by activating brown adipose tissue.
I think the fat burning is the big difference
between these drugs and the older ones
that only reduce your appetite.
These newer drugs
are called glucagon-like peptide-1 receptor agonists
or GLP-1s for short,
and they are liraglutide, brand name Saxenda
which was approved in 2014.
Semaglutide, brand name Wegovy,
approved in 2021.
These drugs are FDA approved to treat obesity.
But for your insurance to pay for them,
you need to have a BMI of 30 or greater,
or you need to have at least A BMI of 27
with an obesity-related condition like high blood pressure,
diabetes, or other evidence of insulin resistance,
or high triglycerides just to name a few related conditions.
There are other GLP drugs
that are not approved for weight loss
but instead approved for the management
of type two diabetes.
Examples of these are Ozempic,
which is also semaglutide,
but at a lower dose than Wegovy.
For your insurance to pay for this medication,
you need to have a diagnosis of diabetes.
You don't need to have diabetes
to get Wegovy-approved though
because it is approved for obesity, not diabetes.
Tirzepatide, brand name Mounjaro
was approved in 2022 for diabetes
but it also causes significant weight loss,
probably even more than Wegovy.
These GLP drugs have been shown in studies
to result in 10 to 22% weight loss
as opposed to the 5 to 10 from the older drugs.
Are these drugs safe?
The most common side effects are nausea,
vomiting, and diarrhea,
as well as other gastrointestinal issues, maybe cramping.
Rapid weight loss also can increase the risk of gallstones.
Signs of gallstones are abdominal pain, nausea,
and vomiting after you eat.
You can take these drugs with antidepressants
or the antipsychotic medications,
but your doctors still need to do
a medication interaction check
of all the medications you take
before adding it on to make sure
you're not getting an unsafe combination
from several medications.
If you want to check yourself,
WebMD has a handy drug interaction checker.
You just put the medications that you take or want to take
and see if there are any warnings.
The other thing to be cautious of is that if you have liver
or kidney disease,
you may not be able to take these medications.
I've focused on weight loss here,
but these medications have other metabolic benefits
that can help anyone
but especially the person who's taking
an atypical antipsychotic medication.
Other things that you should expect to improve
are your lipid profile,
and that includes total cholesterol,
and LDL should decrease.
Your HDL should increase.
And your fasting glucose levels
and hemoglobin A1C and blood pressure
should all decrease depending on their starting level.
These are things that should all be checked
before and after you take the medication.
Even though these drugs are considered safe,
they aren't something where you want to email your doctor
and say, "Hey, I'd like to take Wegovy.
Can you just send it in for me?"
You should expect your doctor
to get some initial blood work
that includes looking at your liver and your kidneys
to make sure that you don't have any compromised kidney
or liver function.
Now, this all sounds really good.
Why wouldn't any and everyone who's gained weight
not take these medications since they work so well?
Well, for one thing, even though most people
don't have any serious side effects,
any medication has the potential for the rare
but serious side effect.
So it's about considering risks versus benefits.
Another thing that can be a turnoff is the GLP drugs
for weight loss are given as injections.
Semaglutide has an oral tablet for diabetes called Rybelsus,
but it's not as strong as Wegovy.
People with diabetes are used to sticking themselves
either to check their blood sugar
or give themselves a shot of insulin.
But if you're not there,
you may not like having to stick yourself.
A huge barrier to treatment though is cost.
Insurance can get very nitpicky about showing proof
that you qualify medically
and that you've tried
some of the other cheaper medications first.
If they won't pay for it,
the cash price for these newer medications
are from $1,000 to $1,400 a month,
and these medications have to be increased gradually.
It takes five months
to get to the final therapeutic dose of Wegovy.
That doesn't mean you won't lose weight
in these first few months.
I've had some patients drop 20 to 30 pounds
in the first couple of months.
This isn't the standard way that it works though.
In fact, the studies show
that people lose this amount of weight
after taking the medication six months to a year,
and as impressive as it sounds to drop weight quickly,
especially if you've got a vacation coming up
and you want to get your sexy back,
losing weight that fast has downsides.
You can lose a lot of weight in your face
and look gaunt with saggy skin,
which can make you look older.
In general though,
you can also have that gallbladder complication
of gallstones from too rapid of weight loss.
In general though, these drugs are designed
to be taken long term.
If you stop after a couple of months,
you can gain the weight back
especially if you haven't changed your eating habits.
So I think the way to use these medications,
if you're using it to lose weight
that you gain from psychiatric medications
is to get the weight off
or get help getting the weight off with the medications
while you also make major changes to your diet,
which those changes will be easier to do
with the way that the medication adjusts your appetite.
The diet changes are not calorie restriction
but eating real food that's rich in nutrients.
And I think with the medication,
it's possible to change your eating habits
in a way that changes what tastes good to you
and makes it easier for you
to not bounce back to craving carbs
once you stop the medication.
That's the next level that you're trying to get to
after you free yourself from some of the weight.
I want to mention
that there are other weight loss medications
that I didn't talk about
for the sake of not getting too complicated.
Going deeper into detail and giving you my opinion
about treatment approaches is the very thing I'll be doing
in my new mental wellness community.
In fact, I have a cheat sheet on different medications
and how we define diabetes and pre-diabetes and things
that will only be available to community members.
So if you want more education like this
in addition to having a premium community
that's free of bots pretending to be me
and trying to sell you drugs on Instagram,
join me at mentalwellnessspace.com.
Thanks for watching.
See you next time.