Obesity Medications and the Coming Revolution in Care with Louis Aronne

James Hill:
Welcome to Weight Loss And, where we delve into the world of weight loss. I'm Jim Hill.

Holly Wyatt:
And I'm Holly Wyatt. We're both dedicated to helping you lose weight, keep it off, and live your best life while you're doing it.

James Hill:
Indeed, we now realize successful weight loss combines the science and art of medicine, knowing what to do and why you will do it.

Holly Wyatt:
Yes, the “And” allows us to talk about all the other stuff that makes your journey so much bigger, better, and exciting.

James Hill:
Ready for the “And” factor?

Holly Wyatt:
Let's dive in.

James Hill:
Here we go.

Holly Wyatt:
Today, we're talking about something huge, a shift that is literally changing the future of obesity treatment. For decades, people living with obesity were told this was simply eat less, move more, try harder. And when those approaches didn't work, the blame fell right back on them.

James Hill:
Right, Holly. The science, the real science has always told a different story. Obesity is a chronic, biologically driven disease as real as diabetes or hypertension. And right now, we're living through the most significant transformation obesity medicine has ever had.

Holly Wyatt:
But here's the truth. Even with these game-changing medications that we've been talking about a lot, many patients still struggle. Access is uneven, there's misconceptions everywhere, and we're only beginning to understand where this field is going next. So today we're going to talk with someone who has shaped this transformation from the very, very beginning.

James Hill:
Yeah, Holly, Dr. Louis Aronne is truly a pioneer in this area. He was doing this decades before anyone else. Louis is professor of metabolic research at Weill Cornell Medicine, and he's the founder there of the Comprehensive Weight Control Center. This is one of the premier obesity treatment centers in the country. For more than 30 years, he's old like me, Holly. He's been a leading voice pushing medicine to recognize obesity as the chronic disease it is. He was doing this long before the new GLP medications made headlines. And I got to catch up with Louis briefly at the annual meeting of the Obesity Society in Atlanta, where he received the George Bray Founders Award, which is really recognizing someone that has contributed, made major contributions throughout their career to weight management.

Holly Wyatt:
Yeah, I'm very excited that we get to have him on the show today. He's a clinician. He's a researcher. He writes the guidelines. He's an advocate for patients that are navigating a system that I don't think still doesn't quite fully understand them yet. Hopefully it's getting better. And his work has helped millions of people get real treatment instead of judgment.

James Hill:
Louis, welcome to Weight Loss And.

Louis Aronne:
Thank you guys so much. I really appreciate you giving me the opportunity to come on and tell people what's going on.

James Hill:
Man, you and I've known each other for decades, and you've been pushing this idea, and I know there were times when you got really frustrated. Things have changed. Talk about the shift and why you're so excited right now.

Louis Aronne:
Well, Jim, we thought for a long time that there's a physiology behind weight management, that something physical is going on, and that's what makes it so hard to lose weight. I started in the field in the 1980s when I went over to Rockefeller University and saw that there was a mouse that had severe obesity. And if you gave it a transfusion of blood from a normal weight mouse, the mouse went down to normal weight. It wascrazy. Like this is the 1980s.

Louis Aronne:
And that was what set me off on this path because it was clear that with mice, we didn't put them on a diet. We just gave them a transfusion. So what that proved is there's something physical going on that is what causes obesity. And if that's the case, then medicine should be able to treat it the same way we treat high blood pressure, the same way we treat diabetes. And that's what got me going. And it's taken a very, very long time. It's actually been 36 years since the first study that I did trying to get people to lose weight. The majority of our studies have failed. I mean, I've done more than 70 of them. And what do we have? We have two big blockbuster treatments. So it's been very tough, but we finally are getting there.

Holly Wyatt:
So blockbuster treatments, what are those two blockbuster treatments, just so the listeners make sure they're on the same page with you?

Louis Aronne:
The first one is semaglutide. Semaglutide, which first came out as Ozempic about seven years ago, and then came out as Wegovi about four years ago, is now become one of the most widely prescribed drugs in the world and lowers blood sugar, but we know it can produce an average weight loss of 16% in people who take it for a year. The other medicine is tirzepatide. Tirzepatide is newer. It was only approved three years ago for diabetes and more recently for obesity, and that's known as Mounjaro for diabetes and Zepbound for weight loss.

James Hill:
So Louis, you've been seeing patients and helping them lose weight for decades. We've tried a lot of medications for obesity and you've been on the cutting edge of trying all the different ones. What's different about these two and how do they affect your patients differently than other things you've tried?

Louis Aronne:
That's a great question. The way these are different, there are a couple of ways. Number one, these mimic naturally occurring hormones, hormones that are released when you eat food. So as far as the fundamental mechanism of action, it should be safe. So you think about it, it's actually GLP-1, which everybody talks about, and that name is given to this category, even though drugs like tirzepatide is both a GLP-1 and another hormone, GIP-stimulating compound.

Louis Aronne:
But GLP-1 was discovered in 1981, and it took a very long time to figure out how to make it into medicine. And so now, if you look at the first approval of a GLP-1 for diabetes, it was in 2005. So drugs in this category, although these are more recent, drugs in this category have been around for 20 years. And for diabetes, they're among the most widely prescribed. I mean, millions, tens of millions of people are taking them. So the key point there, guys, is that it's safe. That we have all the evidence and a growing body of evidence that these medications are safe for people to use. Now, that doesn't mean they're over-the-counter. It's not like people should just be getting these on their own. And that's something we should talk about. People are getting these on their own online and trying to figure out how to give it to themselves. I mean, that to me is crazy. But as a prescription drug, these are transformational.

James Hill:
Yeah, I worry about that too, Louis. You and there are a whole bunch of physicians that understand obesity. They've been treating it for a long, long time, but there are very few of you. Most people get it from primary care physicians who may be well-meaning, but not quite as up on treating obesity or on their own. What can we do about that issue?

Louis Aronne:
I think that accessibility, you know, given the size of the problem, in other words, the number of people who have obesity and the fact that there are so few specialists in the country, there are 10,000 specialists and millions of people with obesity, a lot of people are considering how to do this. So some ways are things like telehealth. Is telehealth a reasonable way to deliver this kind of care? And it's tough to answer that question because our experience is that there are telehealth companies that are doing this the quote-unquote right way. They're evaluating patients properly as best they can through telehealth. I mean, if you don't have the patient there in front of you, is that a good thing? Is that something you can do and then prescribe these medicines?

Louis Aronne:
Personally, I believe that you can do that. If you take a careful history in the majority of people, you can prescribe a medicine like this. However, not everybody agrees. There are physicians who do not agree that that is a good thing to do. They think everyone needs to be seen and examined at least once. So that way, in my opinion, is going to turn out to be okay. But then there are people who are doing quote-unquote telehealth, but they just fill out a form, and they get sent the medicine and they have to figure it out for themselves. That is not healthcare. And when we look at the side effects that occur with these medicines, we're seeing that a lot of them occur in people who have substandard care.

Louis Aronne:
They don't even have anyone. Forget an experienced clinician who knows what they're doing. They don't even have a doctor who's prescribing it and giving them feedback, or they can't get somebody to give them advice if they have side effects. So, in our experience, these medicines are more tolerable than they seem to be because of the irregularities in the delivery system.

Holly Wyatt:
My feeling on it is it is a prescription medication. Definitely, we are getting more and more safety history. And you're right. They've been out there for diabetes for a long time. So that can make us feel good that it's not like they've only been out there a few years. We've been using them in the field for a long time. It's still a prescription. And I always say we want to maximize the benefit and reduce the risk. And if I was going on a prescription medicine, any type of prescription medicine that has the potential of side effects, and these do, I would want to make sure I'm getting my biggest bang for my buck and minimizing that risk. And to me, the way to do that is to work with somebody. And I agree. I'm not sure. I think you maybe can do it telehealth. But I think you do have to have that relationship with a health care provider to really get the biggest bang for your buck. That means get the most weight loss, the best quality of weight loss, not just the quantity, and then minimize the symptoms or the side effects. I'm sorry, the potential side effects. And that's why I think it's so important to partner up and not just get this over the Internet. And I've had people saying, can't you just write me a script? And I'm like, no, it's not just writing a script.

Louis Aronne:
Right. No, believe me, we hear this all the time. And, you know, we have one of our faculty members couldn't, she wanted to come see me. She couldn't get in because we're so backed up. I mean, that's one of the problems is that, you know, we have 11 doctors and five nurse practitioners. So we have a lot of people seeing patients. It takes like six months to get an appointment here because there's so much demand for this kind of care. So what did our faculty member do? She went to an online company and got it and started out. I mean, she's a doctor. She started taking it, and then she came several months later when she had an appointment, and then we took over her care. But I think what we're seeing, so we're going to be working with one of the large online companies, Ro, in order to see what their safety record is. And my belief is that things are going to look good. Dr. David Allison, both of you know, he's working with them. And we've decided to look at safety data from a very large online company and see, you know, what kind of data we can generate that will help us to decide if this is a good thing or not. The biggest problem is we don't have any of that. Even though millions of people are being treated, no one has published a large-scale data. A database like that.

James Hill:
Louis, you have a comprehensive weight center where I think people that are lucky enough to get in there get the best care available. For people that might get a prescription from their primary care physician or even from other sources, are there things they can do to help? I mean, one of the things we've talked to is a lot of registered dietitians who feel like they can help people both managing side effects, looking at diet. What kind of recommendations would you make for people that don't have access, say, to a specialist or a specialized center like yours?

Louis Aronne:
That's a great question, Jim. You know, for a long time, I have been encouraging the dietician community to become obesity medicine specialists to have. And they do have a certificate program. But to me, they're the perfect people to be the point person in a center like ours. We have three registered dieticians. The problem is that it's not always covered by insurance. If they see us or a nurse practitioner, it's covered. If some, under some insurances, unless you have diabetes or kidney failure, you can't see them without having to pay for it. So what we need to do is have a system that encourages them, the patients, to see registered dieticians. So I believe that registered dietitians, as we begin to adapt our healthcare system to the needs of people with obesity, that's what we're going to do. The registered dietitians are perfectly suited to manage. Our registered dietitians are obviously expert in this stuff. They know these medicines backwards and forwards. If they have a patient who is having side effects, they'll tell them, don't take the dose or take a lower dose, or they'll call us and ask us to prescribe a nausea, anti-nausea medicine for them. I mean, there are a variety of scenarios, and the dieticians are really great. So I am totally on board with that idea.

James Hill:
I agree. I think it's a wonderful opportunity for dietitians. We need them engaged.

Louis Aronne:
Absolutely.

Holly Wyatt:
Yeah. So I want to, this is a question I'm getting a lot. So I really want your opinion on this. You said there's two medications, semaglutide, tirzepatide. I would add a third option, bariatric surgery and kind of in the mix. When someone comes to you, how do you decide, like I'm getting a lot of questions, which medicine is best? Which of those three options? How do you kind of think about it in terms of which option you might try first with a patient coming to see you?

Louis Aronne:
Sure. So, Holly, to be honest, I don't know if you guys experienced this, but we wind up prescribing what is covered by insurance. So, again, the typical patient who comes to see us has a body mass index of 37. So that means for a man, they'd be about 260 pounds. A woman would be about 220 pounds. So these are people who qualify for medical treatment, but they may not qualify for surgical treatment. Anyone we see who fits the criteria for bariatric surgery, we would tell them, “Look, you could have bariatric surgery.” But given that we're a center that's well-known for medical treatment, people come, they seek us out because they don't want to take that path. If it doesn't work, we absolutely urge patients to have bariatric surgery. And when you look at the safety of the new procedures like the sleeve gastrectomy and the gastric bypass, when you look at the success rate, it's above, somewhat above tirzepatide, which is the most effective medicine producing about 20% average weight loss. So, you do have options that are even more effective.

Holly Wyatt:
Yeah, I think sometimes people forget that. Surgery's still out there, and it is producing probably a little bit more in some people than the new drugs, but I agree most people are interested in the medications. But let's say insurance isn't the issue. Do you think one of these drugs is better than the other? I know we have one, I think, head-to-head, but I do think there's some individual, in terms of when I have seen certain people do better on one than the other, any clues on that from you?

Louis Aronne:
Absolutely. So, it's very interesting because we do switch people from one to the other. So everyone, I think, imagines that Zepbound, because it's more effective than Wegovy, is what everybody, you know, just take Zepbound. But that's not true. I mean, yesterday we saw two people who said they did better on Wegovy. They felt fuller and they had less thinking about food and they had fewer side effects. And then we see plenty of the reverse where people, you know, they'll start out and they'll do fine with Wegovy, but then maybe their weight loss will plateau and we switch them over to ZepBound and they continue to lose weight. That's something I'm sure, Holly, you've seen plenty of times. So we use both medicines quite a bit. We now have, just to give you an idea of the scale of our program. We have 9,000 patients taking GLP-1s. 9,000 patients. So massive experience that we are developing here. But I think both of them, so let me give you an idea. If someone has a body mass index of between 30 and 35, so that's the lower end of the obesity scale, or if they're overweight, those people, the amount of weight loss that you typically get with Wegovy is more than enough for that kind of patient. So often we would start with that. Or if someone has heart disease, coronary artery disease, because there is an indication that for Wegovy in people with coronary disease, we would use that. On the other hand, someone has sleep apnea, patients with sleep apnea can often get coverage for Zepbound because of the studies showing that it's effective. So we do a lot of that where there are studies showing that there is a specific benefit, we will prescribe that particular drug.

Holly Wyatt:
Yeah, I love that. And also what you were talking about, it's kind of the art of medicine, too. You've learned what to do. And it's not just, we look at the clinical trials, and I think this is sometimes people are just getting the medication and saying, here, you know, it's just we can follow an algorithm. And I'm like, no, really, there is this, you've learned through these 9,000 patients, and there is some nuance to it and some art to it. So I like that people are starting to hear that instead of saying, which is the best drug? It's not like that.

Louis Aronne:
It absolutely is not. And like every medicine for every disease, we'll see one person will feel phenomenal on one of the drugs and they'll say, this is the greatest thing that ever happened to me. And then the next patient comes in and they're like, I feel terrible, you know, what's wrong, and I'm not losing weight and I feel really exhausted. Like, how does that happen? We do not understand. We have no clue right now. And there's a lot of work going into trying to figure out exactly what's going on. But you have to, in my opinion, to do this the right way. If you have clinical experience, you can get people to lose weight. I mean, we see things like, you know, the kind of cases that we're seeing now, because we're known for doing this, we get people who are not successful on even the best medicine, and we get people who are not tolerating these medicines. So, what do we do in somebody who can't tolerate the lowest dose of one of the medicines? What we do is give them less. We have come up with ways to give mini-doses, or what some people call micro-dosing, by using one of the pens that has an adjustable dose. And this is not standard, but as a tertiary care medical center, that's the kind of stuff we do. So we saw someone recently, the doctor was like, oh, this guy can't tolerate anything here, go see these guys, meaning us. So we started him on, it's about 20 clicks to get up to the lowest dose of the Ozempic. We gave him a quarter of that, and he did fine. He started losing weight and felt full. And as we went along, we just gradually went up. So what I'm saying is that there is definitely an art of medicine here. There's an art, and that will help more and more people. So what we start out doing eventually will make it into the mainstream of prescribing. That's the way I look at what we do specifically here at our center.

James Hill:
Louis, one of the things I want you to react to is occasionally we still see out there this idea that somehow taking the medications is cheating, that you haven't done the hard work of diet and exercise. How do you respond to something like that?

Louis Aronne:
Sure. I'll tell a person that it's no more cheating than treating diabetes with medications, including insulin. It's no more cheating than treating your blood pressure or your high cholesterol. It's the exact same thing. One of the most valuable things that happened to me in my career was that back in the 1980s, the Chief of Cardiology here at Weill Cornell was Dr. John Lara, who developed most of the hypertension medications back in the 70s and 80s. And he told me, so one day he calls me into his office and said, tell me about obesity. So I tell him a story about that mice have genetic obesity, you give them transfusion, they go down to normal weight. We're trying to figure out how the body regulates weight. It's a physical thing, and we think that we could develop medication to treat it. What he told me was, you know, what people told me in 1958, so here's 1988. He said, in 1958, people told me, why are you going to try to treat high blood pressure with medication? It's a psychological problem.

Louis Aronne:
People who are under stress, their blood pressure goes up in some cases. So it's really a psychological problem, not a medical problem. We know how that story ended, right? There are now more than 100 drugs in 10 therapeutic categories to treat hypertension. And the risk of stroke is dramatically lower than it was back in the 1950s and 60s. So with that in mind, I said, this is going to be the same thing. People have to take medicine. Maybe they don't need to take it every day as you do in hypertension, but you will need something medical to overcome the physical barriers to weight loss, which, by the way, we know what's going on. It's not like, you know, we may not be able to deal directly with the exact problems that are causing obesity, but we know that something changes in your brain that makes your set point, I'll call it, right? That's a common name, get higher and higher and higher over time, and that's what is causing people's weight to be high and why they can't just turn around. The whole physiology of the system shifts higher and higher. It's not that people don't have willpower.

James Hill:
Yeah, we often say the medications really level the playing field. So now you have a reasonable shot at maintaining weight, just like the people that are genetically fortunate.

Louis Aronne:
Right. That's exactly right. I tell patients it allows your willpower to shine through. Exactly what you said, it levels the playing field. So the physical forces that are pushing your weight up, now we have something to neutralize those. And if you eat well and do physical activity, you'll be able to lose, where before you couldn't do a thing.

Holly Wyatt:
So I love that story about the hypertension. I didn't know that about the blood pressure medicines. And you do look at where we are now. And I think that's what I'm hoping that's where we're going in the field, where we'll have lots and lots of options. And I want to ask you about those in a minute. But before we get there, one difference I see is we now know a lot of people are using the drugs to lose weight successfully, but for some reason, and there's a whole list of them, and, you know, from wanting to get pregnant to not being able to afford it to not being, maybe not having access or maybe just not wanting to be on it long-term or going off the meds. How are we going to deal with that? What are your thoughts? What do you tell your patients if they say, you know what, I want to stop the medication. I've lost a lot of weight, but I need to go off or I want to go off of it.

Louis Aronne:
Sure. What I'll tell people was, look, I'm not going to come to your house in the middle of the night and give you the shot. I promise. It's up to you to take it. If you want to take it, you take it. But here's what we recommend. If you want to take it, take it every 10 days instead of every week. So try to wean down gradually. See what happens if you take it every week. Then try to take it every two weeks. And then if that's all working and your weight's stable, try it once a month. Don't just abruptly stop. We did that study, right? We did that study and we showed that about one in six people are able to maintain 80% of the weight they had lost. But the majority, 80% regained their weight, 20% maintained, 80% regained. And that's not a good statistic.

Holly Wyatt:
Not good odds if you're playing the odds there.

James Hill:
But see, I like that approach, Louis. And what Holly and I often talk about is, I think the future here is figuring out how lifestyle and medications are integrated in people over the long term. And I always say, if medications work for you, want to stay on the long term, that's great. But I do think that the medications can motivate some people to do some lifestyle things that may allow them to maintain the weight either with lower doses, intermittent use, or with no medications.

Louis Aronne:
Absolutely true. I mean, we see. So one of the things that is so exciting about the medicines is that it helps people to comply with the dietician's recommendations and the exercise person's recommendations. As people lose weight, we're seeing again and again that they feel more activated. They feel they're more interested in being physically active. And as far as eating, the issue of quote-unquote food noise, right? You've heard about this. The idea that people have a lot of thinking about food, it absolutely gets better. It diminishes. So to me, that is a sign that these are very powerfully working on the weight-regulating pathways and making it so that it's easier for people to comply.

James Hill:
I love it that you're out there on the cutting edge. You've never been afraid to try new things, even though it's not traditionally accepted in the medical community. I think you've always been willing to push the envelope a little bit.

Louis Aronne:
I have been willing to push the envelope, but in what I would call a medically appropriate way.

Louis Aronne:
Here, we don't do things that people would consider to be, quote-unquote, crazy. You know, someone with heart disease, coronary artery disease, would we give them stimulant medicines? The answer is rarely. But if a cardiologist called me and said, look, this guy has to lose weight. The only thing that works is something that is a stimulating medicine. And there are very few, and we rarely use them now because we have medicines that reduce cardiovascular risk. So we do very sophisticated things here because we work within a medical community. It's not like we're out in left field doing crazy stuff. So what I've been able to do is to practice like doctors practice in our community, in Manhattan. And so by interacting with the patient's physician, you can have a lot more latitude to try different things and see if they work.

Holly Wyatt:
I love that you, like we've talked about, right on the cutting edge. So I would love to ask you, what do you think the next decade of obesity care will look like? And specifically, what treatments do you think are going to be added or coming or, you know, in addition to what we have?

Louis Aronne:
Sure. So, what we're going to see, just in the next five years, there are 15 medicines that are lined up to go to the FDA and hopefully, if their trials are successful, get approved. The first thing we're going to see coming in January is oral Wegovy, the oral form of the injectable, the weekly injectable. I think that's going to be gigantic for two reasons. Number one, it doesn't need to be refrigerated.

Louis Aronne:
When you look at much of the world, they don't have giant refrigeration. Our hospital dispenses our medications. They had to buy another pharmacy for the thousands of patients who are getting medicine that we prescribe. So they bought an entire pharmacy just to have refrigeration for all of the Zepbound and Wegovy. So you won't need refrigeration for these. We've measured it. It takes one-fiftenth the space to store this that it does the other and to ship it back and forth. So things like that are going to dramatically reduce the cost of the medicine. And I've heard, as everybody else has, that it's going to be less than $200 a month. So that is going to be an enormous breakthrough in accessibility.

Louis Aronne:
Affordability and accessibility. So many more people are going to get it. Coming a little bit later in the year, probably by April, will be a new medication, Orforglipron. Orforglipron is a GLP-1, just like Semaglutide, but it's a small molecule. So it's like taking Lipitor or any of the traditional medications. It's not a peptide molecule. So you need less of it. It's cheaper to make.

Louis Aronne:
And I think that, too, added to the oral Wegovy, we're going to see a lot more. If you look at the weight loss with these, it's a little bit less than Wegovy itself. It's not as much as Zepbound.

Louis Aronne:
What we're going to be doing is, just like in hypertension, one of the big lessons the hypertension people learned in the 1960s was that treating people earlier prevented complications and people never progressed to the severe problems that they could have. They didn't develop kidney failure, heart failure, strokes, if you treated them early enough. I mean, in hypertension, when they first started treating people, they were treating people with blood pressures of like 250 over 200. I mean, now when we hear that, we're like, were they crazy? But they didn't really have anything. But what they learned from doing studies was that if they kept lowering the bar, finally getting down to 140 over 90 instead of 250, that people never developed heart attacks, strokes, or had the manifestations that were so common back then. Like we never see this kind of stuff anymore.

Louis Aronne:
When I was a medical student, We would see people with a hypertensive cardiomyopathy where their hearts were very, very thick. That doesn't really happen much now. The same thing is gonna happen treating obesity, that the guidelines are gonna keep going further and further down in weight. And the ultimate model will be that when your weight goes above a certain level, you'll start getting treated with a low dose of a very tolerable medicine. And we won't see the catastrophic problems that we see now where 9% of the population has a BMI of 40 and above. That is not going to happen. That's going to be like having a blood pressure of 250 over 200 in the future. You're never going to see it because we will have widely available, affordable medicines that can treat it. So you never get to that point.

James Hill:
Louis, that's very exciting. How do we ensure equitable access to these medications? Because right now, some of the people that need the most are having trouble getting access.

Louis Aronne:
Yes, that is absolutely true. I think that one of the issues, I don't want to get into pharmacy benefits managers and the whole PBM situation and why are the prices so high, but the point is that these are medicines that are so much in demand that they're breaking the stranglehold that the system has had on the prices of medicines. I mean, you're seeing like when the president is negotiating directly with the CEO of a pharmaceutical company about these specific medicines? I mean, that's unheard of. That's unheard of. So the demand, patients' demand for these is so great that I think that we're seeing action way before we would have in the past or with practically any other disease. So I'm pretty confident that we're going to, again, with the thing that's really going to drive this, is the health benefit that we're seeing. It's not that the government is trying to reduce the price of these because people wanna look good in a bathing suit. It's because, I mean, we published a study last year, last November, with Zepbound. What we showed was that whatever the dose someone was taking, if they had prediabetes, it reduced their risk of developing diabetes by 94%. 94%. People who are taking the highest dose, it was a 99% reduction. I mean, think about the implication of that for the health of people in the country. Think about the implication for Medicare. If Medicare had nobody, you know, all of a sudden there are 94% fewer people with diabetes. There are going to be 94% fewer people who develop diabetic kidney disease and need kidney transplants. And there are probably going to be 94% fewer people who have liver failure from fatty liver disease.

Louis Aronne:
And the list goes on and on. Coronary artery disease. Heart failure. So very, very expensive illnesses are the direct result of obesity. And I think that the cost effectiveness of studies are showing this. If the price of the medicine can be low enough, then everybody is going to benefit. The patient's going to benefit. And the healthcare systems will. So I think this is the first time I've ever seen this and I'm excited to see it where the country is pushing the price of the medicine down to get people the medicine. So what's gonna happen is insurance is gonna cover this. Medicare is gonna cover it. Private insurers will cover it, and then it will be widely accessible.

Holly Wyatt:
I agree with you, and I think this is exciting, and I do think that's eventually how it's going to play out, and that's good. So we have a pill that controls weight, and everybody can have it, let's say. But it doesn't change what we eat, and it doesn't change how much we move, and it doesn't change how we maybe deal with stress or other things. Do you think then is just dealing with weight enough?

Louis Aronne:
Holly, what it's dealing with is not weight, but the weight regulating system. So what it's doing in a certain way is taking people who want to eat more because they don't feel full or they have more thinking about food, and it's normalizing their feeling about food, their interest in food and other aspects. So already, you know, people who are taking these medicines are buying less food.

Holly Wyatt:
Yeah, I understand that. But it doesn't change what they're eating and it doesn't change how much they're moving. We're trying to get more data to see what people are doing. And there's some people I think you take it and start exercising. And, this is not everybody, but I know you can be very successful and not increase your physical activity. you can be very successful and still eat a very small amount of non-nutritious, energy-dense or empty calories and be successful. So I'm kind of getting at that piece of it.

Louis Aronne:
Sure. So can you do that? Yes. So that's where the dieticians come in by making sure that people are well-educated. I think that those kinds of things are very helpful. And the point, like telling people that you're going to prevent diabetes, at least here at our center, we find is an extremely powerful tool for getting people to eat better. We've done about five studies looking at the order of eating food. Nutrient sequencing, it's been called. So what our work has shown is that eating vegetables and protein first before you eat carbs dramatically lowers your blood sugar. And it's almost like taking a medicine. We're doing a study now in India where the health advocates who are in the villages, like in one village we've taught them this way of eating and the other village just got taught general recommendations. So we're doing a trial to compare the two in a rural setting in India to see if we can reduce the incidence of diabetes just with a very simple recommendation like that. So we'll tell people, eat your vegetables first, then have protein. And then if you want to have carbs, it's okay, have it at the end of the meal. So the trick there is that you got to eat vegetables to eat them first.

Holly Wyatt:
I love this. Here's a medication that may allow you to use food as medicine easier. The medication may allow that to develop those habits or make it easier to use the food as medicine. But I love that concept, thinking about food as medicine, physical activity as medicine, that type of thing.

James Hill:
All right, Holly, I think it's time for you to do the rapid fire questions for Louis.

Holly Wyatt:
All right, Louis, you got to be quick. These are quick. These are rapid fire. I have confidence in you. Are you ready?

Louis Aronne:
I'm ready.

Holly Wyatt:
All right. What is one misconception about GLP-1 medications you wish would disappear tomorrow?

Louis Aronne:
That they are not tolerable.

Holly Wyatt:
Okay. If you could have every primary care doctor do one thing differently when treating obesity, what would it be?

Louis Aronne:
I would want them to recognize that obesity is a chronic disease and treat it that way, just like they treat diabetes and high blood pressure.

Holly Wyatt:
What is the most exciting thing in the obesity treatment pipeline right now?

Louis Aronne:
I think that we're now going to triple agonists like Retatrutide. We're going to amylin agonists, which work in a totally different way and are more tolerable, it seems, have fewer side effects, and also work in addition to what we have. There are monthly medicines. We're studying monthly GLP-1 GIP drugs, so once a month shot, and even every three months. So things that will really fit with the lifestyle of our patients.

Holly Wyatt:
What is one habit that reliably helps patients maintain weight loss no matter which treatment they use?

Louis Aronne:
I think that eating vegetables first is going to be very, very helpful. And physical activity. I think that really physical activity.

James Hill:
I'm glad he got that in there.

Louis Aronne:
I think changing physical activity is going to turn out to be critical, even with medicine.

James Hill:
I agree.

Holly Wyatt:
Last rapid-fire question. In one sentence, what does the future of obesity medicine look like to you?

Louis Aronne:
It looks a lot like the treatment of high blood pressure. Your weight goes up. The doctor says, oh, you're in the overweight range. We're going to give you a small dose of this medicine, and you're going to get back down to a normal weight, and you'll just have to take it intermittently maybe every month or two months, and your weight's going to stay the same. You're never going to have a weight problem like your parents did.

James Hill:
Good job, Louis. You handled that well. Holly, let's do a couple of listener questions.

Holly Wyatt:
All right, you do those.

James Hill:
Yeah, I've got one here. This is from a 25-year-old female, really interested in going on the medications, has a primary care physician she loves and is very interested in helping her, but she can't afford it. And she wonders if it's okay to use compounded meds.

Louis Aronne:
That's a very tough question. You know, what do you do in that situation? As a very empathetic practitioner, I would say that if the physician has a compounding pharmacy that they felt okay with, then maybe that would be okay. I would not decide to do it. what we have done is to have people use smaller doses of bigger size medicines, and that is how we have minimized the cost of the medicine. We've ordered medicine from Canada for patients. That doesn't work now because of the tariffs. But there are some ways that we've done it. I think that a lot of the issues are going to be solved in the next few months. The prices are dropping dramatically.

James Hill:
Okay. Here's another one. Are these medications actually safe for long-term use, or are we going to discover problems later, like with Fen-phen?

Louis Aronne:
That's a great question. Medicines in this category have been around now for 20 years. So my guess is that if problems were going to develop, up, we would have seen them by now. But with the large number of people, so are there side effects that we're seeing? Yes, there are different side effects. We see people, their intestinal.

Louis Aronne:
The motility of their intestines slows down so much that they get severe constipation. That's not something we saw in initial trials. So the short answer is there may be things, but not anything like that, like what we saw with Fen-phen. And again, I emphasize that these are hormones, these stimulate hormonal systems that are already being stimulated. So we think that the chance of off-target effects as occurred with fenfluramine are very, very, very low. One other thing I want to mention as far as the last question, what would I do with that patient who can't afford it. We prescribe the older generic medicines. If it's a younger person, right, we would use something like phentermine and topiramate in combination. That costs less than $50 a month if it's prescribed generically. And as a brand, the combination of phentermine and topiramate is $100 a month. So we would do something like that. Or the combination of bupropion and naltrexone, also $100 a month. I would try those first.

James Hill:
Holly, why don't you do one vulnerability question for Louis?

Holly Wyatt:
Okay, I've got one. I've got one ready. So how do you feel watching these new breakthrough medications being used casually for cosmetic reasons on social media and out there? How do you feel about that?

Louis Aronne:
How do I feel about it?

Holly Wyatt:
This is vulnerability. You get to feel. You get to feel.

Louis Aronne:
Right. I, I'm not happy that things have gone in that direction so rapidly. You know, I anticipated since everybody wants to lose weight. I mean, walk along Park Avenue, which is four blocks away here, you see people who don't look appropriately thin, right? They're too thin. So, and we know that dermatologists and medispas are prescribing it for people well in the normal weight range. Like we've seen BMI of 20 people being prescribed these medicines. Do I think it should be done? No.

Louis Aronne:
I don't know what I can do about it. I cannot control that part of the system, so I can't. What we do is treat people who have appropriate issues. Let me mention one thing, however. There are people in the normal weight range who suffer from the complications of obesity, prediabetes. So we see people come from Asia, have a patient who had prediabetes, she gained 15 pounds, that was it. Her weight, BMI was 23 pounds, you know. She clearly had a weight-related complications. Should she be treated? Yes. And we treated her and it's gone. She no longer had prediabetes. She's back to where she was. So, it's a little more nuanced than, but using it for cosmetic purposes, it's something that unfortunately is going to happen when it comes to treating weight.

James Hill:
Okay, we're going to have to wrap it up. Louis, this was an amazing episode, and we didn't nearly get through all the questions we had for you. So I'm going to put you on the spot and ask you to come back in the future and do another segment. And for our listeners, this is a guy that is the best in the world at treating obesity, particularly using the new medications. So send us questions for Dr. Aronne, and we'll find a time to have him back on to answer more questions.

Holly Wyatt:
Yeah, maybe we can just do all listener questions because we have so many of those.

James Hill:
Send a listener questions and we'll do a whole episode on listener questions. Louis, this has been terrific. For people out there who are thinking about going on a medication, I think this episode has been incredibly, incredibly helpful. It's nice to see you out there doing what you do. And it's nice to see you so excited about the future of obesity treatment. So really enjoyed this segment. Thank you for your time. And we'll see everybody next time on Weight Loss And.

Holly Wyatt:
Bye, everybody.

James Hill:
And that's a wrap for today's episode of Weight Loss And. We hope you enjoy diving into the world of weight loss with us.

Holly Wyatt:
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