Why Obesity Care Still Fails People with Fatima Cody Stanford

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's conversation is for anyone who has ever thought, I'm doing everything I'm supposed to do, so why does this still feel so hard?

James Hill:
Or for people who finally got access to medication and thought, this is it, and then realized that there were still obstacles, some confusion, and often frustration.

Holly Wyatt:
Because even in this new GLP-1 era, a lot of people feel dismissed, rushed, or even left on their own once that prescription is written.

James Hill:
And that's what we're talking about today. Not just obesity treatment, but obesity care. Holly, we have a really special guest today. She is emerging as a real star in our field. And she's so busy. We were lucky to get her.

Holly Wyatt:
She is a star. She's not emerging. She is a star.

James Hill:
She has emerged as a star. Let's put it that way.

Holly Wyatt:
Okay.

James Hill:
But she's doing podcasts and documentaries, and she is really going to help us understand this issue. So please welcome Dr. Fatima Cody Stanford. She's at Harvard Medical School, you know, the Harvard Medical School. She's an associate professor, and she is an obesity medicine physician. She works with patients across the lifespan from children to adults, and she's been one of the strongest voices calling out bias, inequity, and broken systems in obesity care. She treats obesity as the complex chronic disease it is, but she also understands how often the system fails the people living with it. So, Fatima, welcome to Weight Loss And.

Fatima Cody Stanford:
Well, thanks for having me. It's a delight to be here with both of you today.

Holly Wyatt:
All right, I'm going to kick us off. I'm going to start this in a little bit different direction because your expertise, you're bringing something we haven't had on the show before. So I'm really excited to kind of cover that.

Holly Wyatt:
Let's start off by why do you think so many people feel, and that's the question, they feel kind of failed by the obesity care system?

Fatima Cody Stanford:
Well, I think there are a variety of reasons why they feel like they have been failed. Let's start from bias and stigma, which, Jim, you really called out in my introduction. We know that over 80% of physicians have a tremendous amount of bias towards patients that carry excess body weight. So when a person comes in to see their physician, and we can go beyond that to our advanced practice providers and go to our nurse practitioners. I think they call themselves physician's associates now. These were previously our physician's assistants. And we can go down the path to nurses, exercise physiologists, and the list goes on.

Fatima Cody Stanford:
There's a tremendous amount of bias towards those that carry excess body weight. The assumption is that they just haven't tried hard enough. They didn't eat well. They didn't exercise hard enough, right? And so if this is the narrative that that person comes into the system with, before the first word comes out of their mouth, they sense that dynamic with that individual. It doesn't matter if they're there with you in Alabama next to my home state of Georgia or here in Massachusetts. I sound like a news reporter, so people can't place that I'm from my home state in Georgia, but it doesn't matter where they are. They can sense that dynamic from being a pediatric patient to a young, middle, or older adult. They sense that dynamic from the moment they walk through the doors or through telemedicine because we're using a lot of that these days. The judgment starts immediately. So are you sure that you did X, Y, or Z? Are you sure? Because look at where you are if you're a person with severe obesity.

Fatima Cody Stanford:
It has to be. There has to be some role that you played that places you here. The snickers when you get on the scale. The fact that you can't fit that hospital gown. You must not have done X, Y, or Z. There isn't the same amount of bias that is with someone that happens to carry a leaner phenotype. Now, that person with a leaner phenotype may not have done any of the things that they were supposed to do, but there isn't the judgment that they come in the door with. And so I think initially that bias and stigma is so overarching that that becomes internalized within the individual themselves. And so they believe that why engage with the system? I think this is what gave birth to the Health at Every Size movement. So this adoption of, well, I'm just going to accept who I am. I don't want to engage with health care practitioners, clinicians, etc., because this isn't a safe place for me. So I think that's, you know, where a lot of this issue surrounding this idea that you are going to be a failure comes from. The bias and stigma that is so highly pervasive and accepted within the health care community and the community writ large.

James Hill:
So I think you are out there trying to establish a different model, a different way of thinking. So walk us through some of the things that you are doing, because I think a lot of people are looking at you as a model for how things could be.

Fatima Cody Stanford:
I think this starts from a system, right? It starts at the system-wide level. If we think about the fact that the average age when a person begins to demonstrate signs of weight bias is 36 months of age, right? 36 months of age. And I'm putting on my pediatric hat here when we start talking about this. So by the time we become clinicians, this is very much entrenched within our thinking process, right? Well, 36 months, this starts early in the household. And so when I say this, then often parents get very offended. They're like, well, I don't teach my kids to have any bias, but yes, you actually do. Because if you're watching or engaging in social media or looking at television or whatever, you're often commenting on the leaner phenotypes as being beautiful or gorgeous or et cetera, and not commenting on individuals that carry a larger phenotype or body size or shape and saying that they demonstrate beauty, et cetera. So then by not calling those persons out as having any type of aesthetic appeal, then you're indicating that they must not. And this then plays out on the playground and et cetera. And this carries into our daily lives. And so I think we have to begin, you know, in early life with recognizing this, because by the time we get to educating individuals and our professional schools, unfortunately, we're so far behind the eight ball that we have to recognize that, you know, the damage has already been done. I think that we have to recognize that this is a multi-sector approach that we have to take. This can't all happen in health care. I think that we have to look at government. We have to look at faith-based communities. We have to look at what's happening in institutions. We have to recognize that this is a multi-sector, multifactorial approach when we're looking at weight bias and stigma. Otherwise, that individual, if we go back to the individual themselves, they're not going to feel cared for and supported because we have to be approaching this from all angles.

Holly Wyatt:
So you depressed me a little bit with the 36 months. I mean, I did not know that. And that's pretty, I mean, you know. So what do we do about that? Can we undo that? Or do we, you know, is it just awareness enough? I believe it's there. It's like, okay, what if we want to take some action about it?

Fatima Cody Stanford:
Well, if you didn't know, Holly, then imagine who else didn't know, right? So if we didn't know this and if we begin to educate and say that we need to stop it at that level so that when we move beyond our preschools into our elementary schools, et cetera, then we can begin to change that narrative so that young children that have obesity don't become scarred adults that then subsequently carry this burden with them throughout their life course.

Fatima Cody Stanford:
We can begin to chip away at what's become the status quo, which is this internalized bias that they carry with them that makes them feel unworthy of any attention. I have patients that, let's say, may undergo therapy or treatment, and they'll say to me, and this is some of that psychological piece, that they don't feel like they deserve to wear, let's say, a size 6. Well, why don't you deserve that? Well, I just don't think it's fair. And I said, well, what do you think about the person that already wears a size six that never struggled with their weight? And then they think about that and they're like, well, I guess they don't feel bad about wearing a size. But because they have this bias towards themselves that may come from that early life interaction with individuals that snickered at them or caught them names because of their body, habit, or size, it's become so entrenched that they don't value themselves, right? And that's problematic, right? So we have to begin to raise the alarm there. And we have to begin to recognize that if we as health care practitioners and professionals can't do the hard work, then how can we expect for the greater population to begin to do the really tough work? It has to start with us. If you can't trust your doctor, then how can we expect the larger community to really do the tough work?

James Hill:
I love it. I think you've outlined the problem and I want to pick up on that. So you as an obesity physician at Harvard Medical School, what can you do and how are you thinking about how you help with the change?

Fatima Cody Stanford:
Well, I do a lot of things, but I'll just talk about kind of me, the person. Before I see an individual as a new patient, I make sure that they're educated about their disease. So I have them watch an hour and 11 minute lecture about their disease process before I will see them. And so people might say, well, is that punitive? No, I don't see it as punitive. I see it as them learning about their disease to help start to undo a lot of the shame and blame that they've placed on themselves. So when they come through the door or through the screen, however I'm seeing them, they begin to realize that, wait a minute, a lot of these misconceptions that I've had about myself have been flawed. This is actually a disease process, and we have strategies, whether there's lifestyle, behavioral, pharmacotherapy, surgical, or a combination thereof, to begin to treat this disease that I have had, whether it started as a child or started as an adolescent, a young adult, middle-aged, or older adult, and that Dr. Stanford is going to use these tools and use a multi-sector approach using, for example, here.

Fatima Cody Stanford:
Whether it's our dieticians, our psychologists, our bariatric surgeons, people like me, obesity medicine, to help address this complex multifactorial disease process. And I can tell you that having just that strategy, such that when they come in to see me on day one, it changes their thought process or the narrative associated with who they are in that space. They recognize that this is a trusted space and I'm not going to judge them for who they are. I'm part of this solution and I'm there for the long term. Most of my patients have been with me for about 15 years. So they realize the chronicity also of this disease. I'm not going to just magically throw a surgery at them or a medication with them and then say, okay, well, you know, it's done.

Fatima Cody Stanford:
Okay, we've solved your disease process. It is a chronic disease, so it requires long-term dedication, and I'm there for the long haul. I'm not going to just treat them and then just disappear into the ethers. And so part of that is engendering that trust and recognizing that this is part of a long-term strategy to address something that may have plagued them for quite some time. And so I think that these are some of the things that I do as an individual, recognizing also that in some ways I'm in a little bit of an ivory tower, right? So the resources that I have available to me might not be resources that are available to many outside of a setting like mine and that those that are able to access these resources is limited in nature. I've published recent papers. I published a paper just recently in the Mayo Clinic Proceedings talking about how their pockets in the country where you have access to these types of resources in this level of training, despite the vast need for individuals with obesity and in our country alone, let alone the world from the perspective of over 1 billion people worldwide being affected by this disease.

Holly Wyatt:
So I want to switch just a little bit, but I think it's related. You know, now we have done lots of podcasts, and I'm sure you talk about this all the time, that the new GLP-1 medications have changed the game or changing the landscape, I think, are changing the dialogue in many ways and starting to, some people at least, think about obesity differently. So kind of what is your thought about these GLP-1s? Are they helping the situation? Are they hurting the situation? How should we be thinking about that in your kind of bigger picture of how we move this forward.

Fatima Cody Stanford:
So I do think that GLP-1s and medications in that category are helpful as a treatment strategy. I don't think they'll solve obesity. I think that people think, hey, GLP-1s and the 30 plus medications that are in the kind of current immediate pipeline will just solve obesity. And I think that that is short-sighted, right? You know, these are one tool or one such tool in the toolkit to treat this disease. I mean, I think this is like we said, a chronic, multifactorial, multi-sector prong approach that we have to utilize to treat patients with obesity. For those that are responders, and notice I was very strategic in that statement, for those that are responders, these can be highly effective strategies. I think it's about using the right tool for the size of the problem. Still, for persons with severe obesity, bariatric surgery is still the most highly effective tool for those individuals.

Fatima Cody Stanford:
For those individuals that undergo bariatric surgery, they will often need medications as an adjunct. I can tell you that about 90% of my patients that undergo bariatric surgery will need medications as an adjunct to a surgical intervention. So that's important to note. For the GLP-1s, it does require chronic use indefinitely. That's important to note. And with current issues with regards to access and coverage in our country, it's important to note that the affordability and access issues are of paramount consideration. I'll just talk about here in my current state of Massachusetts, where I've spent a lot of my professional career practicing obesity medicine, we had the best coverage coverage.

Fatima Cody Stanford:
And notice this, had, meaning past tense, best coverage for these medications up until January 1st, 2026, where all of our four major insurers, which are Blue Cross Blue Shield of Massachusetts, Harvard Pilgrim, Mass General Brigham Insurance, and Tufts, decided to pull coverage for patients with obesity as of January 1st. Now, we see 42,000 patients here at the Mass General Wait Center, so that's a sizable number of patients, and this affected close to 70% of our patient population, for which many were using or currently utilize GLP-1 receptor agonists. Now, the out-of-pocket costs for these medications, if we want to look at semaglutide under the trade name of Ozempic or Wegovy or tirzepatide under the trade name of Mounjaro or Zepbound, these medications out-of-pocket are $350 or $450.

Fatima Cody Stanford:
Now, that's cost prohibitive for many individuals that are not high-income earners, and so they will lose coverage. What will happen? They will regain the weight in 85 plus percent of the time. That is unfortunate for those patients that were responders to these medications, which is a large percentage of those that were on therapy. And so when we talk about the utilization of these medications and look at the Wilding study that showed withdrawal and showed regain, or Aroni study that showed withdrawal and showed regain, and not even having to be in the study and treating, you know, several thousands of these patients, we know what happens is that once we pull back these therapy, we see not only the regain of the weight, but the reemergence of obesity-related diseases when these patients come off of therapy. And so I think that this is an important thing to note as we see insurers not only here in Massachusetts, but also throughout this country, pulling back coverage of these medications, particularly with the high degree of individuals that have developed an interest and wanting to be on these therapies.

James Hill:
So, Fatima, we agree with you entirely. These medications are wonderful tools, but not the magic bullet, the answer. What I worry about, though, is patients and a lot of physicians, primary care physicians that aren't trained well in obesity may use them that way. I think a lot of patients think, this is the medication, it solved my problem, everything is over with. And most of the people that are going to get these meds aren't seeing a specialist like you. They're seeing a primary care physician. Are you concerned about that? And how do we address that potential problem?

Fatima Cody Stanford:
Obviously, the number of specialists while growing, is not at the level that it needs to be to address the total market of individuals that have obesity. So we don't expect that specialists will be able to cover the entire number of individuals that really need therapy. And we're going to need our primary care providers, i.e. Internists, family physicians, pediatricians, etc., to help shoulder this burden. This comes with the need for individuals to be trained on how to provide this care, both at the medical school level and in residencies for those that are physicians, for the advanced practice providers to get some type of training surrounding this type of care. And it's not really rocket science in how to provide this level of care, getting the appropriate education through CME credits and listening to lectures given by persons like myself and others, of which we do many. I've done over 1,200 myself, so I know that they're out there. It's a matter of just taking the time to listen.

Fatima Cody Stanford:
I think that if you just take the time, you, meaning those people, take the time to listen and understand how to appropriately prescribe these medications and mitigate any side effects associated with the use of these medications, that this can be done well and can be done in a way that meets the needs of the patients in a safe and effective way. And I think that primary care can do this. I mean, I don't expect someone to do it exactly at my level. I did three years of fellowship training in this, and there are less than 10 of us in the country that have done that. So not exactly where I would do it, but I would say at a level that would allow the patient to get the highest level of benefit from these medications. But I think they also need to explain that these medications are meant for chronic use. And so if we withdraw the medications, that they can expect a reemergence of whatever chronic diseases were being treated along with the medication and a regain of weight that was lost while they were on the medication. So I think that's a really important education pieces to explain to the patient at the outset, prior to prescription, the initial prescription. And I'm very direct and upfront with patients prior to initiating any type of therapy of what to expect. And then also let them know if, this is really important, if this medication is effective.

Fatima Cody Stanford:
Everyone is not going to respond the same. Average being average. There are going to be just, I explain it like if you were to go to school and take a test. There were the high responders, the ones that got the highest grades. There were the average people in the class. And then there were the low responders. The difference here is that you can't study for this test and get a high grade. It really depends on your physiology. And there isn't anything you can do to will yourself to get the high response. There are a lot of patients that want to do that. I have some highly educated people here in Boston, those MIT professors and Harvard professors, and they think they can will themselves to respond. This isn't that, right? This is just your biology. And that's really important because they want it like, okay, well, maybe if I go work out for three hours, I'll respond better. I'm like, no, that's not how that works. If the medicine works, it works. If it doesn't, it doesn't. It's not something you can do to make it do its job. It will do its job or not do its job based upon your body. So I think that's important.

James Hill:
I want to follow up on that briefly. So given that, and given that the medications are certainly more effective than anything we've had before, what's the role of lifestyle? How do you approach diet and exercise with your patients?

Fatima Cody Stanford:
eah, I think this is a really important point. I'm glad you brought that up. I think that patients need to be aware that lifestyle is still an important component, particularly as we recognize that as patients are losing weight, they're losing fat and muscle simultaneously, right? A really important point is emphasizing protein and fiber. And the reason why protein and fiber are very important is because patients need to be supporting themselves with about one and a half times the protein they think they need. And with fiber is because these medications slow gastric emptying, right? So they're going to need fiber plus the fluids to flush the fiber through the system to really be the healthiest they can be. And then let's talk about the exercise component. So if we're talking about the loss of lean muscle associated with this, and of course, this could be with not only the GLP-1s, this could be with other lifestyle modalities, we need to be really emphasizing strength training, which is not anyone's favorite thing I've learned, even though I'm a huge strength training enthusiast myself. When I'm talking to both male and female patients, they'll be like, oh, I went on a walk or, you know, I went on a run or I went bicycling. I often struggle to get my patients to really engage in strength training.

Fatima Cody Stanford:
And I'm like, well, but what about weights? Oh, well, Dr. Stanford, you know, I just, so you really want me to lift weights? I'm like, yes, I really do. So, you know, we go through all this, like we go in circles and through the woods to grandmother's house. And I'm like, no, we need to really engage in strength training. And so often have to be very prescriptive, like actually give them an actual program. And of course, depending upon what stage of life we're at, what their actual physical limitations are, then I have to be very prescriptive in terms of what I'm giving them. And then for some people, once they really get into it, they realize, oh, wait a minute, that was actually somewhat enjoyable. For some people, it's like, I'm like pulling teeth out to get them into this mindset. Now, once they may see their DEXA results and see something like osteopenia or osteoporosis, then that may be a motivating factor. But the problem is that I don't want them to get to having some type of pathology to encourage them to want to do something. The goal is to prevent them from getting into a situation where they actually have something that they now need to then go backtrack from. And so I would love it if we could somehow get people in the mindset of recognizing that strength training is really important. And so particularly as people are crossing the threshold into middle age, into older adults, I try to emphasize that I want more strength than cardio as we start making that progress into those age groups.

Holly Wyatt:
I agree. The strength training is not many people's favorite. There's always some, but it's not. I agree. And being more prescriptive. Yeah. But being more prescriptive, I think sometimes they just don't even know what to do. What should I do? They're just very unfamiliar and uncomfortable with it. Another thing that's coming up, though, so we're seeing that, but I know that these drugs and our listeners know that they are to be used long term, like other medications, that that's the intended way they were developed. But what we're seeing and what I'm seeing in clinic and what we're seeing even in some of the statistics that are out there is they're not staying on them for various reasons. Sometimes it is they lose coverage and they can't afford it. Sometimes they don't feel great. And even with some adjustments to things to make those side effects better, they're like, I just, I really don't feel great. I want to go off the meds. How do you approach that with what we know thus far we've seen in terms of the data, but real life, not everybody's going to stay on them?

Fatima Cody Stanford:
Yeah. So I would say that the first condition that you stated, usually for at least in my eyes, what I'm noticing in working with patients, just because I have such a high volume of individuals on these meds, it's usually that. I have patients right now fighting with Senator Markey to get coverage for medications they've been on. So our two senators here in Massachusetts are Elizabeth Warren and Markey.

Fatima Cody Stanford:
And they're like going and they're taking it up to the senator to like fight for coverage. So this is how aggressive they are in terms of fighting for coverage. So I find that that's usually the biggest issue for those that are responders. Notice I said those that are responders. For those that aren't responders, this is a kind of a moot point.

Fatima Cody Stanford:
For those that, like when you talk about kind of side effects, usually it's me changing them to a drug that will mitigate side effects. So for example, going from a single agonist to a dual agonist usually mitigates most of the side effects that patients have on a single agonist if they were a responder. So if they were a responder to that GLP-1 category, when I go to a dual agonist, it's more physiologic in nature. And so I'm able to mitigate those side effects that they had on a single agonist. But let's talk about what happens in the situation. For example, CVS Caremark made a deal with Novo Nordisk such that those that have that as a pharmacy benefit manager can only be on that drug for coverage. So let's say I switched them over to a dual agonist and they were like, oh, I feel so much better. Now their insurance may only cover the single agonist and so they no longer have coverage. They can't afford the 450 a month out of pocket. They can afford a 30 copay which is what the single agonist is and so they go off for that reason. So the side effects does become an issue because they can't they can't tolerate the side effects on the single agonist no didn't have issues on the dual agonist but can't afford that and so it's like. So then there's that issue. So this is kind of what you see on a kind of a daily basis.

Fatima Cody Stanford:
So then they come off, not because they really wanted to come off, but I think you see what I'm saying. And so we're kind of caught between a rock and a hard place. We saw something that was effective, no longer can be covered, they don't have the money to afford it, and then we're in this loop. And it becomes very frustrating to patients. For what I end up doing for those patients is I go back to some of my traditional therapies. So I'm one of the old school docs that knows how to use our traditional therapies, Phentermine/Topiramate, Bupropion, Naltrexone, Zonisamide, Metformin, et cetera. And we step back into those agents and often in combination, not all at once. I have to kind of come up with a little bit of a recipe for them and find what works for them, but recognize that our data is not going to be like our step trial or surmount trial or anything of that sort. And make sure that they're aware that we just don't have that same level of data for those therapies as we do. But these are going to be affordable therapies. And so that's really the strategy that I take, Holly, in working with those patients.

Holly Wyatt:
To switch them to a different medication that they can afford.

Fatima Cody Stanford:
They can tolerate and they can afford and mitigate the issues that we were dealing with the GLP-1 receptor agonist.

Holly Wyatt:
Got it.

James Hill:
So, Fatima, you deal with people across the lifespan. Let's talk about children.

Fatima Cody Stanford:
Okay.

James Hill:
What's the future there of treatment? And is there a role for meds? Are the meds helping, not helping, not relevant? What's your sense of the future there?

Fatima Cody Stanford:
Right now, we do have GLP-1s approved for use in pediatrics. Right now, the only medication in that category approved is semaglutide. We do know that the dual agonists will likely get approved for use in pediatric patients. What we find in pediatrics is that, as with other different things, pediatric patients tend to respond in a more potent fashion than adults. So if you look at, for example, semaglutide, they tend to have a better response than adults. They tend to have a little bit less side effects on average. The side effects are the same, so it looks similar. And I'll just, interestingly enough, since I take care of a lot of children and their parents and grandparents, and sometimes even their great-grandparents, I find that the parents get jealous of their kids and their response. Well, I don't understand why she's doing better than I am. And I'm like, well, this is your child. Shouldn't you be excited for them? Well, why does she not get nausea? Well, it's your daughter. Should you not be excited?

James Hill:
They're not competitive here.

Fatima Cody Stanford:
Just a tad. Right? I'm just thinking about a few instances. Obviously, I'm pulling from real data in my brain where kids are doing better than their parents on the same exact therapy. And the parents, particularly the mothers, because I may be also treating their fathers, and it seems to be the mothers that get slightly jealous.

James Hill:
So how young can you use the meds? What age?

Fatima Cody Stanford:
12.

James Hill:
So if you put a 12-year-old on it, they might be on this medication for 60 years.

Fatima Cody Stanford:
You are indeed correct except…

James Hill:
Does that bother you at all or you're okay with that?

Fatima Cody Stanford:
I'm okay with it. I'm completely okay with it. So, you know, except that if it's a female, right? We would pull this back for pregnancy if they decided to have kids. You know there's a lot of, we don't use this during pregnancy. There's a concern about like obviously using this during lactation and things of that sort. So we would pull this back during those key times. For young men, because I also have quite a few young men on these medications, and you would think, so this is how also I get adults that are afraid of needles to use these meds. I say, well, you know, I have a 12-year-old boy in this. They're like, really? A 12-year-old boy? That usually gets all adults encouraged that they can pull this off.

James Hill:
I have one quick follow-up here because I'm always interested in this. So we don't use it in pregnancy. Is that because we know it's bad or we just don't know? But it seems like, you know, epigenetic transmission of obesity, pregnancy might be a wonderful time to get the weight off.

Fatima Cody Stanford:
So there's never been any studies conducted. None of the companies. So, right now, the two major drugs that are out, sema and tirzepatide are Novo and Lily's drug. They have never done studies in women who are pregnant. I hear you in terms of talking about this epigenetic transmission, but we don't know what the safety would be, particularly during a time when we have a fetus that's growing and how this would affect, particularly for people.

James Hill:
It's a tough one to do research on, too, because if you get it wrong, you could...

Fatima Cody Stanford:
Oh, yeah. This would not be great. So, we usually recommend stopping these medications two months prior to conception. And that's pretty well documented, but that's what you would see within the package inserts for both Sema and tirzepatide is to stop these two months prior to conception. You'll also hear this idea, however, in the lay population of Ozempic babies. What does that mean? We have this idea that these medications seem to reduce inflammation, improve fertility, and this seems to be true. There are various studies that are being conducted, or I wouldn't say studies, but reviews that are being published looking at kind of this periconception time span and what happens during that time span. And one of my mentees actually just published a recent study in JAMA looking at the GLP-1 surrounding conception and saw some favorable results with the use of GLP-1s in the periconception period. So I think we'll see more and more data coming out specifically surrounding this.

James Hill:
So stay tuned on this one.

Holly Wyatt:
Yeah. You just were talking about the injections and some people not liking the injections or having maybe a phobia for needles. And so I wanted to get, we now have an oral semaglutide or oral Wegovy. Thoughts on that? Do you think it's going to be as, and I know we have the science, the data that's been published from the trials. In the real world, do you think it's going to be equally as effective or what are your thoughts on it?

Fatima Cody Stanford:
Yeah, so it's interesting. It's just been on the market for about three weeks now, the Wegovy pill. The dose is 1.5, 4, 9, and 25. I hope I got that correct because we haven't really used it as much in real life yet.

Fatima Cody Stanford:
Let's talk about the pill and and I think that kind of pros cons obviously there are people that prefer to take a pill with Wegovy pill you do need to take it fat on it in a fasted state and then you need to not take anything after it for about 30 minutes. If you have side effects which people are more likely to have side effects from a single agonist than a dual agonist etc you're going to have those side effects every single day, right? As opposed to if you take an injection once a week, most people will have side effects that last for, let's say, 24 to 48 hours, and then they don't have to have those again until they redose themselves, right? But if you have side effects from a pill, then every single day you have side effects. So I think that's important to know. Some people don't like the idea that they have to kind of time it around, like, okay, I gotta take it, then I gotta fast, then I gotta, you know, it's a little bit more involved. The out-of-pocket price for the pill, I was a bit surprised that they made it so close to the injection. So the out-of-pocket price for the 25 milligrams is $299 or $300. I hate when people market $299, so let's just call it $300, whereas the out-of-pocket price for the injection is $349, or let's just call that $350. Why are they so close in price if the production of pill is so much cheaper?

Fatima Cody Stanford:
I would have, I'm surprised that they didn't price that at a much lower price point to make it much more accessible to individuals that may be of lower socioeconomic position and may need access to this type of therapy and don't have access. So I was really disappointed to see that that wasn't priced at a point that would make it more accessible to the broader population. So these are just my thoughts, high-level thoughts about that.

Holly Wyatt:
I think it's important, you know, some of my patients are, you know, if you're a person that you need that cup of coffee when you first get up, like you could, this and that was not going to be a good fit for you because absorption is really important and being very strategic about not eating anything and four ounces of water and all of that. So, yeah.

Fatima Cody Stanford:
I really was hoping with particularly the orals that we would have a price point that was significantly lower to make it more accessible to individuals that did not have access to these these therapies. I understand that that companies need to recoup their. You know, R&D. I'm very well aware of that. And I am sympathetic to that. But I also recognize that a pill costs a significantly lower amount to produce than an injectable where you have the receptacle and then the solution and then all. I mean, there's so many different parts to that. So I just was hopeful that we would see a lower price point that made it much more accessible to the population, not only here in the U.S., but the broader global population.

James Hill:
All right, Holly, I think you're up for the rapid fire.

Holly Wyatt:
These are my favorite. These are our listeners love these because it's just rapid fire come off the top of your head. These will be these will be easy for you. But I think it kind of gets them them thinking about these things. So rapid fire. Here we go. One myth about obesity you wish would disappear.

Fatima Cody Stanford:
Eat less, exercise. What is this? It's kind of eat less, exercise.

James Hill:
Eat less, move more.

Fatima Cody Stanford:
Yeah.

Holly Wyatt:
Yeah.

Fatima Cody Stanford:
Let's move more. Yeah, that's, I don't.

Holly Wyatt:
Because it kind of makes it think that's all that it is. Right?

Fatima Cody Stanford:
That it's all it is. And then you just.

James Hill:
And if you don't do it, it's your problem.

Holly Wyatt:
Right.

Fatima Cody Stanford:
Yeah. I don't like that one. If we could get rid of that, that would be great.

Holly Wyatt:
Love it. One phrase healthcare providers should stop saying.

Fatima Cody Stanford:
Hmm. Did you really exercise today or did you really..

Holly Wyatt:
Is that all you really ate? Did you eat anything else?

Fatima Cody Stanford:
Yeah but you did that like kind of questioning them like they already told you the answer and when you come back and ask it again it implies you don't believe them.

James Hill:
You're lying I can't believe you.

Fatima Cody Stanford:
Yeah.

Holly Wyatt:
One thing patients should never feel ashamed about.

Fatima Cody Stanford:
Who they are. Just show up authentically as yourself and be true to who you are.

Holly Wyatt:
Yeah. Here's one of my favorites. One habit that matters more than people realize.

Fatima Cody Stanford:
I'm saying this now this is not something I do well. Probably sleep. But I do not do that well. So I do not do that.

James Hill:
I think the data shows that sleep is so involved in eating, exercising, mental health.

Fatima Cody Stanford:
Yeah.

Holly Wyatt:
And I don't think we think about that as much as being as involved as it could be in body weight regulation.

James Hill:
And evidently, most of America has sleep issues. So it's widespread.

Fatima Cody Stanford:
Yes.

Holly Wyatt:
And the last one of the rapid fire. One thing you want listeners to remember today.

Fatima Cody Stanford:
Please don't think less of yourself if you happen to have excess weight. You are beautiful the way that you are. We are all works in progress. And we can work to be our best self. My goal always is to get you to the happiest, healthiest weight for you.

Holly Wyatt:
Oh, I love it. I love that you put happiest in there. It's not just about health. It's health and happiness. I love that one.

James Hill:
So, Fatima.

Fatima Cody Stanford:
Yes.

James Hill:
Talk about this issue. Is this a personal issue for you? How do you think about it? How does it, obviously, this is something you've grabbed hold of and are out there. How personal is this issue for you?

Fatima Cody Stanford:
I would say it's highly personal, particularly as a Black woman. The demographic that has the highest rates of obesity here in the U.S. happens to be Black women. So I've seen this touch home, and when I say home, those that are around me my whole life. And what we don't often see are Black women kind of at the forefront of really addressing the issue. When we look at the researchers, when we look at the policymakers, when we look at the thought leaders, there aren't really people that look like me in that space. And part of why I've gravitated toward this work was that I didn't see that. So I find this to be highly personal when I've seen those around me continue to struggle and not seeing people that they can readily identify with be part of the solution.

Holly Wyatt:
Love it. All right. What's one thing you got wrong or maybe learned, kind of changed your thoughts about in your career? You know, sometimes we, as you know, there's things I learned in my career, or I thought this was really important, and then the data changed, or I studied it, and I learned, I discovered that I was kind of wrong. Jim and I did a whole show, Things We Got Wrong.

James Hill:
We ran out of time before we got through everything.

Holly Wyatt:
Things we got wrong as the science progressed, or as we learned more. Something kind of in your career that you thought was true at one point, and now you say, eh.

Fatima Cody Stanford:
Gotcha. So, I mean, I definitely was part of the camp that it was mostly lifestyle earlier in my career. So if we go back to the late 90s, early 2000s, very much of the thought process that we got to, okay, so let's get people to exercise and move more and eat well. And if they do that, that must be the answer to the problem. And I think I had a really true aha moment when I was in residency. I mean, I had been taking care of a patient of mine that had severe obesity. I was an internal medicine pediatric residence. And so this was in my third year of residency. I rushed into the grocery store one day and my patient was at the checkout counter with her grocery cart. So I had a chance to survey her grocery cart and I had been spending, you know, years kind of going over what she should be eating. But here I get a chance to see exactly what she's eating. She had defended her kind of weight set point, you know, for many years. This, you know, I'm not a huge BMI fan, as I think most people know, but she had severe obesity and defended this within five pounds the whole time I've been taking care of her. And so as I'm talking to her, she's like, hey, Dr. Stanford. I'm like, hey. And then I'm like talking to her, but I'm like surveying her cart the whole time. She catches me at one point and she makes a statement and she says, see, Dr. Stanford, I did everything you told me to do.

Fatima Cody Stanford:
And her cart was pristine. All the right proteins, all the fibers, all the fruits, all the vegetables. It was as if she were shopping for me and I could have just taken her cart and just run out the grocery store.

Fatima Cody Stanford:
Fast forward two weeks later, I was in the emergency department covering a shift on the adult side. I'm not on the pediatric side, so on the adult side. And when I go in and see this woman, this woman just so happens to be her cousin. I'd never met this cousin. She's like, I think you are my cousin's doctor. And I'm like, okay, you know, so I'm doing my stuff. And she said, you know what? I'm getting so tired of my cousin. She's always making me go work out with her. Okay, so I have two major data points about lifestyle here. She's eating well, right? I just saw her grocery cart. I'm meeting her cousin randomly in this shift that I'm covering in the emergency department where she's telling me, volunteering this information that I'm not asking for, on a shift that she has no idea I'm covering. I'm not an emergency doctor, right? I just happen to be covering this shift. That she's exercising all the time, but she's defending the set point, right? And it was really an eye-opener that, there's more to this story.

James Hill:
Interesting. Okay, Fatima, I want to give you one minute to talk to our listeners who are thinking about losing weight, maybe starting a weight loss program, to give them sort of some hope about the future.

Fatima Cody Stanford:
Absolutely. So for those who are beginning this journey, or maybe just, you know, still pre-contemplation, like, do I really want to take this journey, I would say that this is really the right time to begin that journey. We have a variety of tools to help you on your journey and we have people that are really invested in making sure that you are not alone in this process. Make sure that you are working with someone that values you for who you are and recognizes that this is not a one-size-fits-all equation. When I'm working with patients, I know that the patient that's in front of you or the patient that's behind you is not you. And we're going to tailor the program that we have to fit you and only you. And recognize that the process won't always be easy. But just because it’s not easy doesn't mean that it won't be one that brings you immense joy in the end. And it's about improving your quality of life, getting you to the happiest, healthiest weight for you.

James Hill:
Holly, I hope you see what I've done here. Fatima, I usually sum up the episode, but you have just summed up the episode better than I could.

Holly Wyatt:
Clever, Jim, clever.

James Hill:
Yes, beautiful. See, how experienced. Fatima, this has been amazing. This is what the top of the line weight management looks like. And again, you are doing a lot out there. Make sure you help train the next generation of physicians that understand this a little more and are able to help people.

Fatima Cody Stanford:
I have over 100 mentees, so I want to go and crawl and hide somewhere most of the time, but I have way too many people, so I am doing that work, Jim. You have no problem there.

James Hill:
Fatima, I believe you 100%. I know you, and I know your energy.

Fatima Cody Stanford:
Yeah, so probably too much. I need to go hide and crawl under a rock and hide somewhere. Not a rock because it's too cold right now. Some warm blanket.

James Hill:
So for our listeners, send us questions. If we get a lot of questions, we'll pressure Fatima to come back on and answer some of your questions. I know where to find her, so I can track her down if necessary. This has been an amazing episode, Fatima. Thank you, thank you. And 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.