Medical Interventions in Obesity: Devices and Medicines


Dr. Tirissa J. Reid is an endocrinologist and expert in obesity medicine. She is assistant professor of medicine here at the Columbia Metabolic and Weight Control Center.

Dr. Reid joined Dr. Hyesoo Lowe on an episode of Columbia Surgery’s podcast Conversations and Curbsides. The two doctors discuss a range of treatments for obesity, from devices to medications. 

The following is a transcription of the discussion, and is lightly edited for context and clarity.  

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Dr. Hyesoo Lowe

There seem to be a lot of remedies for weight loss. Let's talk about some of the medical therapies of weight loss. What can we offer them?

Dr. Tirissa J. Reid

Right. So lifestyle changes are the initial intervention for everybody. That includes dietary adjustments, behavior modification, as well as increased physical activity. If that has not gotten them to their goal, that's when we look at the next level, which would be either medical devices or medications as the next step.

DEVICES: INTRAGASTRIC BALLOONS:

Dr. Tirissa J. Reid

When I say medical devices, you may be wondering what exactly those are. One example that many people are aware of are the balloons, or intragastric balloons.

Dr. Hyesoo Lowe

Tell us about that.

Dr. Tirissa J. Reid

So it's literally a balloon filled with either saline or gas, that is placed in the stomach endoscopically, that is to say, with a scope. And it's in there for six months. So, of course if you have something taking up most of the space in your stomach, you're feeling full all the time, you eat very little and you lose weight.

However, one of the downsides to that is, after six months, you have to remove it. We would expect then, if it's not there, it's not going to have an effect. You would see rapid weight gain, although everything depends on the specific person. 

If somebody needs to lose a lot of weight for a specific purpose, like they're trying to qualify to get on the transplant list, something where they really need to urgently lose weight quickly, that's when I think of it as an option.

Dr. Hyesoo Lowe

I see.

Dr. Tirissa J. Reid

But just for day-to-day dealing with weight and trying to lose weight, it is probably not the first one I would go to. And most importantly, it's not covered by insurance. So you're paying about $10,000 for something for six months of weight loss.

Dr. Hyesoo Lowe

It's temporary.

DEVICES: CELLULOSE HYDROGEL

Dr. Tirissa J. Reid

One of the other devices that has come out in the past five years is called cellulose hydrogel. “Plenity” is the brand name. It's a really interesting idea. It's considered a device because—even though you take these capsules with water before a meal—they open up in the stomach, and the substance in there is a type of fiber that we cannot absorb in our intestines. So, because it's not absorbed into our bloodstream, it's not a medication, it's considered a device. 

Dr. Hyesoo Lowe

How long do they stay there though?

Dr. Tirissa J. Reid

So, you drink with the water, it turns into a gel, a three-dimensional gel that takes up about a third of your stomach space. Then, as food is leaving your stomach, the gel exits with it, through your digestive tract. So it's kind of like a temporary balloon. 

It's that similar concept of taking up space, but again, it's not absorbed systemically. Its effect is really just due to having it in your stomach, and feeling full. But it's considered a medical device, even though it's a capsule. 

So that's a really good thing, especially if people are concerned about other side effects that could happen. Maybe some people might have some constipation or diarrhea, something like that.

That's been out for a few years and that can give a greater average weight loss than with lifestyle interventions. 

MEDICATIONS OVERVIEW

Dr. Tirissa J. Reid

And then we look at the medications. It's been really exciting over the past decade, but I'm hoping for more, because if you think about other conditions like hypertension or cholesterol, there are 50 different medications, right?

Dr. Hyesoo Lowe

Good point. We have so many choices.

Dr. Tirissa J. Reid

A hundred, and it's like for weight, oh, we have six. So…

Dr. Hyesoo Lowe

Not so much…

Dr. Tirissa J. Reid

In terms of the medications for weight, what's most interesting is we start to think about obesity as a chronic disease. The new medications are being approved for long-term use. And that's really important because like I said, it's not about a quick fix. It's about finding something that's able to help you long term.

In terms of meds, we've had Phentermine since the ‘50s. It was put out and FDA-approved back in the 1950s. And it can help in terms of increasing metabolism and decreasing appetite, but it does have limitations.

NEW MEDICATIONS

Dr. Tirissa J. Reid

Then, over the more recent years, between 2012, 2014, we actually had a trio of medications come on the market for weight management.

MEDICINES: QSYMIA AND CONTRAVE

Qsymia and Contrave are both medications that are, themselves, combinations of medications that had been in use, previously, as single agents. And we found that putting two together gave even greater weight loss. But at lower doses, often that can help decrease the risk of side effects. 

MEDICINES: SAXENDA

Dr. Tirissa J. Reid

In addition to those, we had a medication called Saxenda, or Liraglutide, which is a daily injectable, come on the market.

Dr. Hyesoo Lowe

Now that's a diabetes medicine, right?

Dr. Tirissa J. Reid

So, under the name of Victoza, and in doses going up to 1.8 milligrams, it's marketed and FDA-approved for diabetes. But, of course, they noted one of the side effects of it was weight loss. So they actually went back and did studies to see what's the most effective dose for weight loss. And the dose for weight loss is actually greater than the dose for diabetes.

So if your goal is weight loss, it would behoove you to be on the Saxenda, because it goes up to higher doses of three milligrams as compared to 1.8 for diabetes.

Dr. Hyesoo Lowe

And is that safe, if you don't have diabetes, to take a higher dose than what you would give a diabetic patient?

Dr. Tirissa J. Reid

Absolutely, absolutely. And that's part of the beauty of this class of medications—along with Semaglutide, which I'll include in this class, and which is one of the newly approved medications for weight management.

Dr. Hyesoo Lowe

Very exciting.

Dr. Tirissa J. Reid

The reason that these are fine to use in patients who don't have diabetes is because number one, this type of medication is actually kind of an analog, similar to a hormone that we actually have in our bodies, already. And this hormone is actually put out after eating a meal and it gives a signal to the pancreas that, “Hey, there's sugar in the bloodstream, try and put out some insulin and get rid of that.”

But also, the other signals are to decrease your appetite because you've eaten and to make you feel more full. And again, this is a hormone we already have in our body, but when we put it out, the hormone, it gets broken down after about four to five minutes.

Putting a molecule on it, in order to make it last a day in Saxenda, or a week in Wegovy, you have those other effects like the appetite suppression, increased sense of fullness around the clock.

Dr. Hyesoo Lowe

And this hormone being GLP-1?

Dr. Tirissa J. Reid

Exactly. GLP-1, yes.

Dr. Hyesoo Lowe

So prolonging the desirable effects for weight loss.

Dr. Tirissa J. Reid

Exactly, and the effect in terms of blood sugar only happens after you've eaten a meal. So it doesn't come into play otherwise. So that's why it really has been a game-changer.

We've done studies in patients who are overweight or have diabetes, and found that their levels are lower on average of this hormone. 

And we think that's one of the reasons why patients who have weight-loss surgery see that their diabetes goes away so quickly. We see this level of hormone increase significantly. And that's just one of the factors, not the only one.

Dr. Hyesoo Lowe

Got it. So this is quite a game changer, and I think I saw in the New England Journal that there were excellent outcomes. They even compared this medication with weight-loss surgery. Is that right?

Dr. Tirissa J. Reid

So I'll say for every medication we know there's a bell shaped curve. You always have some people who are not going to respond at all on one tail end. On the other tail end, you have super responders, and then you have the average patient in the middle.

The average weight loss was about 15%. And when you look at the super-responders, of course you have people who are losing 20%.  I have patients who have lost 20% on this medication. And that's the thing that is coming close to having bariatric surgery.

Dr. Hyesoo Lowe

That's amazing.

Dr. Tirissa J. Reid

If you want more information, I'll just let you know that I'm an author on an article that gives all of the details on these medications.

Dr. Hyesoo Lowe

Excellent. So we will post that article on our show notes if you want to, all the details on side effects, the types of medications, this will all be available to everyone. 

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