What Comes After GLP-1 Success with Ken Fujioka

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:
Jim, for decades, obesity medicine lived in a world, I would say, of modest expectations. If a medication produced 5% weight loss, people got excited. And if someone lost 10%, that was considered a huge success. And then suddenly everything changed. We now have medications producing 15, 20, even 25% weight loss in some patients, numbers that used to exist only in bariatric surgery. But here's the part nobody fully knows what to do with yet. People are losing weight faster than our healthcare system knows how to support them.

James Hill:
Yes, Holly, and the questions are getting bigger fast. What happens when someone stops these medications? And it seems that a lot of people do stop them? What happens to muscle when you're taking these medications? What happens to your metabolism? What happens to someone's identity when their body changes dramatically in less than a year?

Holly Wyatt:
And maybe the biggest question of all, are we entering the end of lifestyle-based weight management? Or the beginning of a completely new version of it?

James Hill:
Wow, great question. Well, Holly, you're in luck because we have the perfect guest today to help us think through that and other questions. Welcome, Dr. Ken Fuzioka, who has spent decades treating obese patients in the real world, long before GLP medications became a cultural phenomenon. He was one of the first physicians, Holly, to devote his career to treating obesity. There are very few people like Ken that have been doing this for decades. A lot of people are doing it now, but when Ken started, there weren't very many people doing it. So he's an endocrinologist and director of the Nutrition and Metabolic Research Center at Scripps Clinic in San Diego, where he also runs the Center for Weight Management. He's authored over 100 scientific papers and served as principal investigator on more than 100 clinical trials in obesity and related diseases. He's worked with all of the medications in the past and current who have been developed for treating obesity. His center sees roughly 1,000 patients a month. He sees what works and what fails and what scares people and what people misunderstand and what comes next after the headlines. And that perspective is rare. Ken, welcome to Weight Loss And.

Ken Fujioka:
Pleasure to be here.

Holly Wyatt:
And I'm going to add one more thing. Ken is one of the most practical obesity clinicians that I know. I couldn't believe we hadn't had him on the show before because this is what we need. He knows how to talk about this. He's not trying to win one side. He's been out there. He's very practical. He has real help for people that are trying to build healthier lives in the middle of this really fast-moving field. All right, Ken, are you ready to give us some of your wisdom?

Ken Fujioka:
You know, Jim brought up something that I actually just wrote a book about, of trying to become a weight loss doctor when it was not good. It was really bad. We had, as you know, Fen-phen clinics popping up everywhere. I trained. Believe it or not, I did a fellowship in endocrine. I did one in GI, and I did one in nutrition. And so I'm a little socially delayed. But I questioned whether I should have done this. You know, really, I was like, what am I doing? Because things got so bad. And my big fear right now is that this might repeat just for some of the reasons you've already mentioned.

James Hill:
Oh, we're going to have fun talking about this, Holly, because we say the same thing, Ken. It's like, man, on one hand, this is so exciting. But on the other hand, we've been here before. Is it going to be something that's a flash in the pan? Everybody tries it. They give it up and we go on to the next thing.

Holly Wyatt:
Yeah, I'm holding my breath just a little bit. I'm excited and I'm holding my breath. Just saying what might come that we don't see yet. I think a lot of us who've been in the field for a long time and have experienced Fen-phen and have experienced, you know, some of the other things are kind of like, okay, wait, I've felt this way a little bit before and then things changed.

Ken Fujioka:
I'm sure you guys know when it really showed its face was when there was a shortage. So we have the shortage of Tirzepatide and Semaglutide, and then all of a sudden you had compounded GLP-1 coming out of the woodworks, just like the old days with Fen-phen.

James Hill:
Fen-phen, right? Everybody was trying to get it.

Ken Fujioka:
Yep. And the thing is, they haven't completely gotten rid of the compounding. It's much less, but it's really clear that, you can buy a compounded GLP-1 from a foreign country for literally actually less than half the price of what most folks pay for the real deal. So, of course, they can undercut everybody and it's still in California, we're still seeing it. So, that's one thing we're worried about. And as you can imagine, we have quite a few emergency room visits. We've had well over a thousand over the last two years, I believe, just for this reason, because the dosages are off, there's things in there that shouldn't be. So again, that's one of the things we're seeing that we're very concerned about.

James Hill:
We get so many questions about that, Ken. And what we always say is that the problem is you don't know what you're getting. Some of it may be perfectly fine, but the reason that these companies go through all the trials and everything is to make sure you know what you're getting.

Ken Fujioka:
Yeah. People forget the FDA doesn't just police the research, they police the manufacturing. So you know it's the real thing. And the biggest problem, actually, we're seeing in California is concentration. The concentration is off, so patients are getting much higher dose than they really should be getting, and they're getting sick.

Holly Wyatt:
Wow.

James Hill:
Oh, wow.

Holly Wyatt:
We started with the negative. Let's step back a little bit, because there is a lot of good. And I think for all of us who've been in the field for a long time, this is one of those points where we're seeing something the field move and finally we're getting weight loss in a range that Jim and I talk about makes people happy. That happy weight loss where they really feel satisfied with what's going on and it's the first time in the field where I've had so many patients reaching that number. So let's talk a little bit about that how do you describe this moment historically in obesity medicine. How does it kind of fit for you.

Ken Fujioka:
It makes my job fun. I get patients to lose weight. And like you said, many patients are getting to their goal weight, which I never dreamed we would do. Way back, when I did my first feeding study on some of the earlier GLP-1s, we're going, “Wow, we're cutting this food intake by 20, 30%.” Now the newer ones, they're cutting them by over 50%. So yeah, we're going to get people to goal weight all the time. You brought up some of the other questions we have now, well, then what do we do now that they're goal weight and we're trying to get the dose as low as we can because they're still losing.

Holly Wyatt:
Wow.

James Hill:
Another thing we get a lot of questions about is, okay, I want to go off the meds or I want to reduce the meds. I want to look at maybe lower dosage or intermittent use. And what we say is, well, the science isn't there, but I know a lot of people are experimenting with that. How do you handle that with your patients?

Ken Fujioka:
A couple of different ways. And I hate this term micro dosing. But with that said, you end up going to the lowest dose. And what's happening, especially with cash pay patients, which it is impressive to me how much people are willing to spend. That is a big chunk of their income to pay for these medications. And so a lot of them end up on a pill form. And you probably saw the stuff that came out, I think it was this morning or last night on switching patients from the injectables to a pill. And it kind of works, not for everybody, but for a big chunk of the patients, it works great. And the pills are cheaper. You can dose them really low. They do great. So that's one avenue we're doing. The other one is, which, and I'm glad I'm talking with you guys because this is completely off label, but you can start going. And the data is very clear. And somebody at our clinic published this is that you don't have to inject every week. You can inject every two weeks. That's fine. Cause again, the half-life of these things is a week. So yeah. So what if you wait two weeks, obviously saves on costs. So I'm sure the companies don't like that, but the fact is it works, but you brought this up earlier. You're going to have to be on something, though, forever. Because, again, if you stop it, it's real clear the weight's going to come back.

Holly Wyatt:
But we're seeing a lot of people stop it. Maybe they've been six months and they feel like a lot of their habits have changed. They now feel like they want to at least try to see what happens if they go off. They don't maybe remember what it felt like before the medications. And some people, I have some people who don't feel great on the drugs, even on lower doses. It's just, it has some side effects. So people are going off. So do you think there's any role for weight loss maintenance doing something other than staying on the drugs?

Ken Fujioka:
The only patients I'm seeing who were able to keep the weight off, the ones that didn't have that much to lose in the beginning. Again, as you know, a lot of patients lose over 50 pounds on this, that group, they usually need something. And what happens is they figure it out themselves. So they'll stop taking their med. They won't see me anymore. And then all of a sudden, about three or four or six months later, they'll come back and they'll go, “Dr. Fujioka, the noise is back. I need help.” So then we got to restart them. And, again, you brought up another, I hate to be the downy kind of guy, but then you worry about, well, gosh, did you lose a bunch of muscle mass? And then you replaced it all with fat, and now I'm just going to make things worse because I'm going to take more lean tissue off. And, again, nobody, as you know, has really done these studies.

James Hill:
Holly and I have always been very interested in weight loss maintenance. And as you said, the meds for the first time help many people reach their goal weight. We couldn't do that with lifestyle. But one of the areas we're very interested now in behaviorally, weight loss maintenance is different from weight loss. So if the meds are doing the heavy lifting on weight loss, most of our behavioral programs in the past have been geared toward weight loss. Now, I think we've got an opportunity to change things a little bit, focusing on weight loss maintenance, and that's a different strategy. But I think the future is a combination of meds and lifestyle. In other words, using every tool we have. So from a clinician, even in patients for whom the meds are working, what do you think is the role for lifestyle in your patients?

Ken Fujioka:
Oh, it's huge. And I think Holly said this, they're seeing, you know, even with the meds we have now, you're seeing 20 to 25% weight loss. That 25% weight loss are all the patients that are doing the behavioral changes. There's no doubt in my mind. I mean, you know, they're exercising, they're doing all that. So one is you get more weight loss, but two, that's the group that, you know, if they got a shot at keeping the weight off, that's the one that's going to do it. I will say this, though. I have noticed in, as you know, some of these drugs are approved for teenagers. And I have several now just, you know, just barely getting out of this. They got away to college, things like that now, and have come back. And they keep the weight off without the drugs. And I don't know if it's being an adolescent, your mind's more plastic, or they've been able to do the behavioral changes better than anybody because they kind of grew up with it, so to speak.

Holly Wyatt:
Or their environment's changing and they kind of maybe had this in place when their environment changed. I always say when someone moves or there's a different kind of chapter in their life, it's a prime opportunity to put some new habits in place because things are changing anyway. It's not going to be the same. So can you do it? I don't know that's very interesting.

Ken Fujioka:
Yeah. But again it's just anecdotal. I had no data for that.

James Hill:
But that's pretty cool though. We talked to Lou Aronne. You guys who know how to treat obesity, I think, are doing such a fantastic job, but so many people get these meds from primary care physicians and don't get me wrong, they're well-meaning and everything. They don't know a lot about how to treat obesity and your outcomes are probably closer to the clinical trials, but in real life, what do you think's going on out there?

Ken Fujioka:
It's scary. And the scariest thing to me is that to them, more weight loss is better. So you have patients, they're driving up the dose very, very quickly, and they're getting rapid weight loss, which you and I both know, the data is very clear on this if you lose weight too quickly, you are going to lose more lean tissue. That's real clear. And we know that from the bariatric surgery, surgical literature, even in the sleeve, if you lose too quickly, you just lose too much bone mass. And there's clearly, obviously we do a lot of bariatric surgery in our clinic, but there's, you just can't get over how much more osteoporosis we see in these fast losers. So the one is, is that education, education, education, and they don't need to lose really fast. If they're losing one or two pounds a week, that is fantastic. They don't have to lose three pounds or four pounds. And then again, they don't have to go to the biggest dose.

Ken Fujioka:
It's not so much the primary care docs, but I find it's, I hate to say this, it's these medispas and telehealth programs where you have somebody who really has no training whatsoever in some of this stuff. I just had one patient. She never saw somebody train this. She just saw a PA the whole time and the PA was just handing out the drugs. It was brutal because she, her biggest problem was a complaint of fatigue. She was just beside herself. So she says, “You know, I think either something's wrong with this or I need help.” So she said, “Maybe ,I better get the real thing.”

Holly Wyatt:
Yeah. And I think sometimes the cost is related to how much you're taking. So, if sometimes going up on the dosage increases the cost. And so, you kind of got to look and see what's the driver for where you're getting the medication from.

Ken Fujioka:
So true. Financial gain is a real problem in this area. And I mean, you guys remember the old Fen-phen days. It was, you're looking, unfortunately, at people who desperately want to lose weight and you have people taking advantage of that.

James Hill:
So Ken, when you see a patient now, you have a couple of, well, you have several options available, but you have a couple of really powerful meds. How do you approach sort of individualizing treatment for your patients?

Ken Fujioka:
The first thing is, I hate to say this, is what's going to get covered? What's going to be least expensive? So that's the first thing. So, you know, and most of us that have an electronic medical record, we can go in and we can find out whether it's going to get approved or not. And if it just says excluded right off the bat, I go, “Okay, we got to go cash basis if this is what you want to do.” And we'll do that. So first thing is what's covered. The next one is then, is am I looking at a patient who's going to struggle, is really going to have a tough time? So if I got a big patient, usually a big male with type 2 diabetes, I got to break out the biggest guns I can find. So maybe I'll go with tirzepatide. My group that seems to do exceptionally well, and I don't need to break out as big of guns, is postmenopausal women. And you know, there is some fairly good data showing that these GLP-1s work better in women. And my guess is because their weight is more physiologic. They're good at hanging on the weight. So women, especially if they're not tall, in San Diego, we have a fairly large Asian population. So, you know, might be five foot tall, but she might be, you know, say 180, 200 pounds, but man, they respond really well to semaglutide. I don't even want to go to the top dose because they're going to lose too much. So again, it's just using what I have. And again, if cost is a real issue, then we'll go the pill route.

Holly Wyatt:
So that's kind of the art. I always say the art of medicine, where you're getting in there and you're figuring out what's working for this individual. And that's so hard. We don't get that from clinical trials. You get that from patients in your office and trial and error a little bit, but in a way that you've been trained to do it safely, I guess, is also important.

Ken Fujioka:
Yeah.

James Hill:
[18:21] Ken, how concerned are you and how concerned are your patients about potential loss of muscle?

Ken Fujioka:
Oh, it's like pulling teeth. I can't get them to exercise. I mean, if I could find a pill that makes you exercise, I'd be the happiest guy around. It is hard. I will admit, I'm kind of the same way. I personally don't enjoy going to the gym. I love going surfing. I love riding my bike, but to get myself to lift weights, I mean, I built a little gym in my house, little man-cade thing just so I do it. But I struggle to get that infamous 30 minutes, two or three days a week. So I feel for the patients, I get it. Some guys like it. They seem to get into it. My female patients, it can be tough. Some of them get into it, some don't. And it's almost to a point to where I say, look, I'm not going to give you the med unless you start doing resistance training. That's how I feel like I got to leverage or do whatever I can. But yeah, if you can find a way to get people to exercise, you guys, you've just hit a home run.

James Hill:
Yeah, I don't have that magic bullet. I wish I did. But, you know, we've done a lot of or several podcasts with some of the muscle physiologists talking about the single best thing you can do is resistance exercise and increase protein a little bit. And that's probably the best option you have to try to maintain muscle mass.

Ken Fujioka:
Yeah.

Holly Wyatt:
Well, and I guess now we're talking a lot about the function of that muscle. Are we really looking at the right thing? Is it really, you know, we're losing maybe lean mass or muscle and those are different. I understand that. But then it's like, okay, you know, just like bone, not all bone is the same, right? We look at bone strength and fractures and stuff like that when we evaluate bone, there may be, we need to be evaluating muscle a little bit differently too. Have you seen any signs in your patients that they've lost muscle in terms of function or strength or not being able to do daily activities.

Ken Fujioka:
Tough one. Mainly because to get through my door, many of the patients have to have a BMI of 35 or higher because we're just too busy. So I'm seeing the really big folks and you probably know this, the minute you get off, say about 15, 20 pounds, they are moving so much better because of the decreased inflammation. So I'm struggling to find that. But what I find is, let's say, I got a 300 pound male. He's a big guy, six foot tall. And so now I've got his weight down, we'll say 50, 60, 70 pounds, keeping a motivated exercise seems to fall off that initial, “Okay, I'm not hurting so much. Now I can go do my thing.” And then I don't know if it's loss of muscle or whatever, but now all of a sudden the exercise becomes, seems more difficult for whatever reason. And again, there's so many reasons. I don't know what to tell you there. Again, because we've had these drugs for a while now, it gets so frustrating to get them totally involved, lifting weights, doing everything, men and women, but then all of a sudden after about a year, they just kind of lose that spark.

Holly Wyatt:
That's concerning because I think, you know, the weight is important, but that's not everything in terms of being healthy. That's one of the things are these drugs producing a physiological state by dropping our intake so low. And if you stay on them, keeping that intake so low, you can survive with very low energy flux is what we call it, instead of a high energy flux, without doing much physical activity and keep your weight down, is that really a good thing? Or is that not what being healthy is going to look like? These new drugs are allowing that to happen, I guess.

Ken Fujioka:
Oh, yeah. And the new ones that are coming out are scary potent.

Holly Wyatt:
Tell us about that. What do you think is coming and what excites you about what's coming?

Ken Fujioka:
You know, just the science of just combining more and different satiety hormones. You know, yeah, sure, we have GLP-1. Then you got tirzepatide, which is GLP-1 and GIP. But then now you have triples coming out. I'm looking forward to glucagon as an addition because, as you probably know, it does have the potential to maybe spare some muscle. It's amazing to me. The first time somebody came to me and said, “Hey, Ken, we want you to look at glucagon for weight loss.” I said, “You're crazy.” I said, “I'm going to make everybody diabetic,” and not realizing that its job is to get energy available. It doesn't care where it gets it from. And the brain, which can't run off fat, says, look, I want ketones or I want glucose. So hence, it shuffles everything in the right direction to burn fat. So that has me the most excited is glucagon coming into the picture. Amylin also has some data showing that they also save muscle mass. We looked at it eons ago. I mean, like, close to 20 years ago when the amylin company was in San Diego and we had hints of it. But as you know, that old stuff, you had to inject it three or four times a day to get significant weight loss. No one was going to do that.

Holly Wyatt:
Yeah. But now they've changed that. So I do think we're going to be seeing some amylin compounds in the future for sure.

James Hill:
Ken, you probably have some patients who don't respond to the meds. What do you do with those patients?

Ken Fujioka:
The first thing I do is actually a genetic study. So as you know, these satiety hormones, are going up into the hypothalamus and trying to get to the MC4 receptor. But there's various proteins you've got to go through to get to that receptor, to tell the body to stop eating, and it's okay to burn calories and that kind of stuff. And we do have one medication now called Setmelanotide, which will work on that defect. And I've now found a couple. It's rare, but you're right. It's probably at least 1 in 20, maybe 1 in 30, just do not respond to these. And it's very frustrating for everybody.

James Hill:
Oh, I bet.

Ken Fujioka:
There's no way you're not taking it, but no, the fact is. And so I'll start looking for these genetic defects. That's the first thing I'll do. The other one is sometimes I got to just say, okay, I'll just take weight maintenance as my goal. And that's how you do it. Because some of these patients, I know we're exercising. I know they're making some of the right changes. So it's just, they got a set point that just doesn't want to budge.

Holly Wyatt:
We talked about more than one reason why people gain weight or struggle losing weight, struggle keeping off so many different pathways. And yes, these new medications have kind of hit on a pathway when you really overwhelm it. And that's what they're doing. It's supra physiological GLP-1 levels. I don't know if you've ever been in a trial where they're measuring it. I'm like, “Whoa, it's off the charts.” I mean, it just hit the system as hard as you can, basically, and sit on those receptors. And so that for a large number of people seems to kind of cause the system to say, okay, you don't need any food and not think about food and so forth. But that's not the only system in play or a reason why people struggle. And I think we're seeing that. So while I think this changes everything, I think there's before the GLP-1s and after the GLP-1s when it comes to this field. I still think there's other strategies, other treatments we're going to need to be able to really pick and choose and use specific treatments for different people.

Ken Fujioka:
Yeah. There was one change in the labeling for the new drugs now that I think is a good thing. And again, it's for these syndromic obesity patients that I'm now starting to find because they just don't respond to the GLP-1s. It used to be that right, the first thing it says, okay, this is for weight loss. And then I would say, but don't combine it with other weight loss drugs. That's been taken out now. And now it's going to say, don't combine with other GLP-1 drugs. Again, these syndromic patients, you really got to throw everything at them. You put them on setmelanotide, you put them on a GLP-1. Sometimes you even got to put them on topiramate. And then you're doing all the B mod you can, you're trying to get them to exercise. It takes a full court press on some of these folks because their hypothalamus is just wanting to get their weight way up there.

James Hill:
So, Ken, as someone who was in on obesity treatment in the early days, where do you see obesity treatment going, say, in the next decade or two? What's coming? And especially answer that from a lot of our listeners who are struggling with their weight. What do you see here for the future of weight management?

Ken Fujioka:
One of them is what you folks have been talking about is maintenance. How do you maintain the weight? Before it was always just get the weight off, but no, now it's maintenance. So that's one of the biggest ones. And then the other one is, and you guys hit on it, is the fact that this concern of lean tissue loss is very real. I mean, just the other day, I feel bad because this woman was 50. We got her to lose 50 pounds, but now she has osteoporosis. That's just brutal. So we need to figure out how to, this maybe had nothing to do with the drugs. We need to be better at identifying patients that are at risk for losing all this lean tissue. Maybe I need to do a dex on everybody before I do that or something like that. Because again, the bone loss can be quite impressive. And as you know, this hits women because estrogen is what women use to keep their bones intact. But as they lose weight, estrogen level falls dramatically. In fact, after menopause, the only way they're going to get estrogen is through their fat cells. Whereas with men, their testosterone level actually goes up and the data is very clear. They actually do a little better in terms of this, you know, lean tissue mass. And we think it's, again, basically the difference between testosterone and estrogen.

Holly Wyatt:
So it sounds like I always say maintenance is becoming sexy, which excites me, weight loss maintenance. And then are you doing DEXAs or checking body composition before, during, and after? Or is that something you think maybe you might start doing? Or where are you with that?

Ken Fujioka:
So we're trying to find an inexpensive way to do it. But yes, we are. So the easiest way is just to do bioelectrical impedance. So just to get a feel for, you know, how much lean tissue they have. It's cheap. You can do it. We can do it. So every new patient gets that. If it's a woman that I think is going to be at risk, I'm going to make sure that either they've had a DEXA or you're right, I'm going to do a DEXA and not necessarily for body comp, but for bone density, make sure I'm not hurting them. Because again, with the newer drugs, you're going to see this phenomenal weight loss. As you know, there are some in the makings, but they got a long way to go where they're going to actually try and build lean tissue while you lose fat. But again, to me, that's sci-fi stuff in the future.

James Hill:
Wow. Holly, you want to do some questions?

Holly Wyatt:
Yeah, let's do some listener questions.

James Hill:
Okay, I'll start. Here's one, Ken. I've lost 40 pounds on a GLP-1 med, and for the first time in my life, I'm terrified of regaining weight. Is that fear rational?

Ken Fujioka:
Yes, it is. I only know because patients have come back and I've never seen anybody so dejected if they regained all their weight. And unfortunately, it was usually insurance would stop covering it. So in January, a lot of the insurances stopped covering any of the GLP-1s. And so here it is, we're in May, and have these patients coming back just in tears. So it is. Your best bet is to make sure you're doing all the lifestyle changes. And again, this is where you need educated health care providers.

James Hill:
I think you know this is. When people start out on losing weight, all they're focused on is reaching that number on the scale. One of the things we've started doing is asking people to start, assume the meds are going to work, think about now what's your long-term plan, are you going to stay on the meds, are you going to do lifestyle. So I think part of it is getting people to think just beyond getting the weight off. That's only part of the goal is what's after that.

Holly Wyatt:
Thinking of it when you start. All people really care about when they start is losing the weight. But can I start to think about what is my plan after that? And that's really the reason we wrote the book, Losing the Weight Loss Meds, is because we were seeing so many people that for whatever reason, maybe they lost insurance coverage or maybe they didn't feel good on the meds or whatever. And there was no strategy. And that's a plan, something that you could try. It doesn't mean that it works in everyone, but for some people, let's at least give them what we know could work.

James Hill:
And if you don't have a plan, you're likely going to regain the weight for sure.

Ken Fujioka:
And that'd be easy to study. Half the group gets a plan, half the group doesn't.

Holly Wyatt:
Well, we're kind of studying that a little bit, so we're looking into that. So here's another listener question. “I'm eating so little on my medication,” and I hear that a lot, right? Barely. They're having to really push to get anything in “that I honestly don't know how to prioritize nutrition anymore. What matters most? What should I eat if I can't eat very much?”

Ken Fujioka:
Protein, protein, and more protein. We actually now routinely tell our patients to take a multivitamin as well as calcium. And you probably know this, America's terrible at fiber intake. A lot of times now we've got to add fiber. So we're adding a lot of stuff. Another nutritional issue that we saw way back was, and it's not being taught, is that when you're on these meds, you end up lowering your total water intake because you do it from the food side, but you also do it, there's an independent effect of these things to just tell you not to drink fluids. And obviously, I'm dealing with a lot of constipation left and right. And so the first thing, we're just trying to, oh, yeah, I guess I'm not drinking fluid. So, yeah, we push all that. But answer your question, protein, protein, protein.

Holly Wyatt:
Yeah. I think some people, they feel nauseated when they drink water, even. They just really don't have that drive to eat or to drink. And that, yes, can be a big problem. And I think that's sometimes why you see people end up in the emergency room, because hydration, electrolytes, not eating, not drinking. And then if they have any type of vomiting, you can be in a serious situation.

James Hill:
All right, Ken, here's another one. My insurance stopped covering my medication and I feel panicked. Realistically, what can I do in that situation?

Ken Fujioka:
Hopefully, you can afford the pills and your Medicare. As you know, come this summer, it's going to be $50 for patients. So Medicare, we're okay. Medi-Cal supposedly is going to follow, but it may be several months. But let's say, you're 50, you're not on Medicare, you're not on Medi-Cal. I think you're looking at the cash options, which are getting lower. And my prediction is you're going to see another price war. There's just too many things coming out and I think there may be another drop coming.

James Hill:
All right.

Holly Wyatt:
So the oral meds, we've been involved in some of the clinical trials with them. To me, the key with the current oral medications is you've got to be really specific about how you take them so that they're absorbed.

Ken Fujioka:
Correct.

Holly Wyatt:
And how has been your experience with that? If people just get up and take them with their coffee in the morning, I don't think it's going to work.

Ken Fujioka:
Correct. It's got to be water.

Holly Wyatt:
So how are you talking to your patients about that?

Ken Fujioka:
Pretty much. It's kind of almost like taking thyroid. You've got to take it a certain way. Fortunately, it's only 20, 30 minutes max and they're going to absorb it. But yeah, no, that has to be in there. And there is one, the weight loss isn't quite as good. So sometimes you might have to switch him to the Orforglipron, which doesn't require any kind of rigmarole. You can take it with water, you can take it with coffee, you can take it with beer, it doesn't matter. But to go the other way, you know, if they'll say they want the bigger weight loss, which you're going to get with semaglutide oral, then they're going to have to follow that. And maybe they can't do it. That's a real tough one. And I find the women, I hate to say this, are really good at it, and the guys are not.

Holly Wyatt:
Yeah, we can say that. Let's say that. But the one that doesn't require it yet, that's not out yet, right? That's coming.

Ken Fujioka:
No, it's available now.

Holly Wyatt:
It just got available. Okay. All right.

Ken Fujioka:
Now available.

Holly Wyatt:
Now available.

James Hill:
All right.

Ken Fujioka:
I mean, it's crazy. And as you know, you got massive doses of semaglutide. You can give 7.2.

James Hill:
Wow.

Holly Wyatt:
Right. And part of that is because it's broken down. I mean, it's in a container, you know, a wrapper, we call it, a snack or a wrapper. But most of it is, doesn't get absorbed. Most of it. And that's why you have to put more in because most of it's not going to get absorbed. I don't think people understand that. That's how important it is to have it in that special snack. We call it a snack wrapper that allows it to not be broken down in your stomach and for it to actually be absorbed into your bloodstream.

Ken Fujioka:
Correct.

James Hill:
Okay, Holly, it's time for your favorite segment.

Holly Wyatt:
What is that, Jim? Rapid fire?

James Hill:
The rapid fire.

Holly Wyatt:
Okay. I think Ken's going to be good at this.

James Hill:
Put Ken on the hook for the rapid fire.

Holly Wyatt:
All right. Rapid fire. Just what comes to the top of your head. It's kind of like just boom, whatever you think. All right. GLP-1s, breakthrough or disruption?

Ken Fujioka:
Oh, definitely, breakthrough.

Holly Wyatt:
Okay. Most misunderstood thing about obesity.

Ken Fujioka:
I'm going to be biased here that obesity affects different races differently. And we have a high Asian population. Obviously, I'm half Asian. But you can't get over how poorly they tolerate weight gain. And as you know, the BMI cutoff is not 30. It is 30 for Caucasians. But I learned you're supposed to use white now, not Caucasian. I found that odd. But anyway, for agents, it's 25. That's a big difference.

James Hill:
Yeah.

Holly Wyatt:
Okay. Biggest mistake clinicians make with weight loss medications?

Ken Fujioka:
More is better.

Holly Wyatt:
Agree. Most underrated obesity treatment tool?

Ken Fujioka:
Weighing daily.

James Hill:
Oh, we like that, Holly.

Holly Wyatt:
Yeah. See, I love these questions. One thing the public still gets completely wrong about metabolism?

Ken Fujioka:
Ooh, what does the public get wrong?

Holly Wyatt:
Maybe even metabolism or weight loss.

Ken Fujioka:
Boy, again, I would guess more is better or faster is better.

Holly Wyatt:
Faster is better. Yeah. I know what you're going to say to this. Most important thing patients should protect during weight loss.

Ken Fujioka:
Their lean tissue.

Holly Wyatt:
Or their bone. Well, I guess bone is considered.

Ken Fujioka:
I hate to say, no, you're right. You know, I hate to say muscle loss. Okay, no big deal. And like you said, we really don't know, even if your muscle is smaller, is it worse? It may not be. It may be fine. But bone, no, that's something that we're starting to see. And I hate causing a problem with weight loss like osteoporosis.

Holly Wyatt:
All right, here's one more. Let's see if you have what you think about this. One obesity medicine prediction that sounds crazy now, but will look obvious in 10 years.

James Hill:
Ooh, good one.

Ken Fujioka:
Man. I guess it would be glucagon. I think that it has a shot at being something that directs weight loss in a good way. But I could be completely wrong. It could be just as bad as standard weight loss.

Holly Wyatt:
Yeah, but adding that to that might change things. I agree. That's going to be good.

James Hill:
All right, Ken. We close every episode with what we call the vulnerability segment. These questions are less about science and more about the person behind it. So we're going to ask you a couple of vulnerability questions. Holly, you want to go first?

Holly Wyatt:
No, I just did rapid fire. You go.

James Hill:
Okay. After decades, and it is decades because I've known you for decades, after decades of treating obesity patients, how has this affected you emotionally? You personally, emotionally?

Ken Fujioka:
It's funny you say that because I have a book coming out this summer just on this issue. In other words, I talk about trying to become a weight loss doctor in the 90s and how bad and just it was terrible. So it's been a real roller coaster ride. No doubt about that. I mean, you know, here it is, Fen-phen Days. We find out there's valve thickening and pulmonary hypertension. And I'm getting sued because patients were trying to get it pushed up to a federal civil suit. And I'm hating. I'm going like, what did I do? And at the same time, not even months later, I'm testing the very first GLP-1 exenatide. And I'm going, oh, my God, this is physiologic. This is going to work. So it's just been a major roller coaster. With that said, now, and I look back on it, I feel really good. I feel like I've done some good in this world. I can sleep at night and happy with what's transpired.

James Hill:
Wow.

Holly Wyatt:
Yeah.

James Hill:
Fantastic.

Holly Wyatt:
All right. Before we close, I like to ask our guests just one final question. If someone's listening only remembers one thing from this conversation, what do you hope it is?

Ken Fujioka:
Exercise, resistance training, please.

James Hill:
Wow. Holly, my gosh.

Holly Wyatt:
Lifestyle coming in.

James Hill:
Oh, wow.

Ken Fujioka:
We got the drugs. We need other stuff now.

James Hill:
I think you're right on. We welcome the drugs, but we believe they're still an important role for lifestyle.

Ken Fujioka:
Oh, yeah.

James Hill:
Well, Ken, one thing I've always appreciated about you is you've never separated the science from the person sitting in front of you. I've known pretty much all the early weight management docs, and I'll tell you, I think patients who get to see you are very, very lucky because I think you bring the science to the person, and you really care about the person. And I think that has come through in your work over all the years.

Ken Fujioka:
You’re very kind.

James Hill:
Well, thank you so much for spending time with us. We'll look forward to reading your book when it's out. You want to tell us the name of it?

Ken Fujioka:
The GLP-1 Doctor.

Holly Wyatt:
Oh, my goodness. All right. That's going to be exciting. I can't wait to read that.

James Hill:
We will have you back on after the book. Well, Ken, thanks so much. And thanks to all of our listeners. Keep sending in questions. We do read them and you can get good questions on the air. So we'll see you 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:
If you want to stay connected and continue exploring the “Ands” of weight loss, be sure to follow our podcast on your favorite platform.

James Hill:
We'd also love to hear from you. Share your thoughts, questions, or topic suggestions by reaching out at weightlossand.com. Your feedback helps us tailor future episodes to your needs.

Holly Wyatt:
And remember, the journey doesn't end here. Keep applying the knowledge and strategies you've learned and embrace the power of the “And” in your own weight loss journey.