Pills, Injections, Surgery or Diet – What’s the Best Weight Loss Plan for You?

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Many people want to be healthier versions of themselves. Taking that first step is the hardest part. What are you stepping into, and will it work? If you’re in a place where you’re finally ready to lose weight and are committed to success, Leena Khaitan, MD, MPH, can help. The Director of Bariatric Surgery provides data on surgical options and valuable information on other weight loss alternatives.

Pete Kenworthy
I don’t remember the last time there was a weight loss craze that involved drugs, right? I mean Keto, sure. Intermittent fasting. We did a podcast on it. But a weight loss drug that actually works.

Macie Jepson
You know, weight loss drugs kind of scare me. The last craze that I remember was back in the ’90s. Do you remember Fen-phen? Fenfluramine/phentermine, I think it was. It really did seem too good to be true. And sure enough, it was. One of the two drugs there caused cardiac damage. And I don’t really recall any huge breakthroughs until now. And we’re hearing everything about Ozempic originally used to treat diabetes. Wegovy is another one.

Pete Kenworthy
Yeah. This is what I want to know. Are these pills so revolutionary that they’re going to put bariatric surgeons out of business? And what about diet and exercise? You know, when’s the right time to take the plunge into an alternate weight loss option? Hi, I’m Pete Kenworthy.

Macie Jepson
And I’m Macie Jepson. And this is The Science of Health. You know, those are really good questions, Pete. These drugs are becoming major tools in the weight loss battle. But more options mean more confusion about what is right for the individual. Here to take away that confusion is Dr. Leena Khaitan who specializes in bariatric surgery at University Hospitals in Cleveland. Thanks for joining us.

Leena Khaitan MD, MPH
Thank you so much for having me.

Macie Jepson
What took so long? I mean Fen-phen was in the ’90s.

Leena Khaitan MD, MPH
Well, we’ve had a lot of drugs in between like Adipex. We had Qsymia. You know, and a lot of those are still in the arena, but for a weight loss medication to be approved for weight loss, it just had to show 5% weight loss, total body weight loss. So, they didn’t have to show a ton of efficacy. Medicines like the semaglutides, tirzepatide, where they are the game changers is because they are the GLP one receptor agonist. And so, what that means is they are far more effective in weight loss, and we’re seeing levels of weight loss with these medications that we’ve never appreciated with any other medications on the market.

Pete Kenworthy
And just so we’re clear, one of those ones that you just mentioned is what we know by the brand name Ozempic, right?

Leena Khaitan MD, MPH
Correct.

Pete Kenworthy
Tell me the drug names again and what the brand name is.

Leena Khaitan MD, MPH
Semaglutide is Ozempic, and tirzepatide is Mounjaro.

Pete Kenworthy
Okay. So, how do these work? And why are they different? Why are they better than they used to be?

Leena Khaitan MD, MPH
Yeah. So, if you think about like Adipex, for example. That medication we took for weight loss and it helped you not absorb fat. People didn’t like the side effects because it gave you diarrhea, and the weight loss was not as impressive as these newer medicines. Now that we have these medicines that really function by hitting the receptors in the intestinal tract…that’s what makes them different, okay…they are far more effective in helping people to lose weight because essentially they do two things. One, they decrease your appetite, so they make you not as hungry. And two, they slow down your intestinal tract, so when you eat, it kind of keeps you full longer. And those are two of the mechanisms by which surgery also works. And so that’s why people keep comparing the two.

Macie Jepson
And we’ll talk about that comparison and what is right for whom and why and all of that a little bit later. It’s very important. But before we get to that, let’s talk more about those side effects. You mentioned uncomfortable side effects, but Fen-phen, I mean, those were some serious side effects.

Leena Khaitan MD, MPH
Yeah. So, we have seen a lot of medications have serious long-term side effects. For example, in the state of Ohio, you can’t take, phentermine is actually back, but only for three months at a time here in Ohio because of those cardiac side effects that were appreciated before. There are other medications that have never even made it to the United States because they cause psychologic effects. And the truth of matter is that we know that hunger, obesity, you know, this is a multifactorial disease. And finding that kind of one trick pony, one medicine that’s going to treat all of it is going to be hard. And no matter what medicine you take is going to have a side effect. So, I mentioned the Adipex gives you the diarrhea. And then these newer medicines, the GLPs, what they do is they make you feel a little fuller, but at the same time they can also give you really bad kind of nausea. Some people actually have a more serious side effect where they vomit with these medicines. And most of these medicines are injectable, so a lot of people aren’t comfortable giving themselves injections either. So, there’s a lot of things to consider when use using these medicines. But for a lot of our patients, they are extremely effective in helping them lose weight.

Macie Jepson
You know, you mentioned that obesity is a disease, and when we started recognizing that rather than saying laziness, willpower issue. No. Disease. First of all, why is it considered a disease? And did that change the fast track or the importance of finding more solutions?

Leena Khaitan MD, MPH
Absolutely. So, Medicare recognized it as a disease, I want to say in 2011 or 2012. And that was the first insurer to actually credit obesity as a disease. Since that time, we’ve seen an increase in interventions for obesity. It’s become much more mainstream to talk about it and not have that stigma of, oh, they’re the big person. They’re the fat person. You know, they must be big and dumb. You know, we’re realizing that this is truly a disease that our patients face, and as healthcare providers, we really need to help our patients with that. And over, I think through COVID, people became more attentive to their health because they were less distracted with the rest of life, right? And COVID was affecting people in such severe ways. And we also recognized during COVID that obesity also was a very big risk factor so that risks of dying with COVID, risks of being hospitalized with COVID increased exponentially for those who were obese. And that was really scary. And we realized that we really need to take action on this as healthcare providers.

Pete Kenworthy
So, we want to make sure we touch on all the tools that are available right now. Right? And we’re talking about surgery and pills or medication. When is the right time to consider this instead of diet and exercise? Cause we don’t want to get away from diet and exercise, right? That’s always the first recommendation I presume, right? But then we also have these other options.

Leena Khaitan MD, MPH
Absolutely. So, when you think about weight loss, it’s actually not just diet and exercise. You got diet and exercise; you have medications; we have surgery, and then in between we actually have this whole field of endoscopic options as well, which don’t involve any incisions, are a little more effective than medicine, a little less effective than surgery. So, we have a whole spectrum of things to offer our patients on this journey. And really consumers are taking ownership of a lot of this themselves and investigating these different routes as well. So, diet and exercise, Pete, you hit that on the head. You know, there’s no weight loss method that will work unless people take accountability for their lifestyle, their health and the way that they live. You know, making the choice to prep your meals for the week versus going to the fast food restaurant, you know, and grabbing your meals on the go, that’s a deliberate decision that our patients make, you know, saying that I’m going to take this time to go for a 15 minute walk or go to the gym and work out.

Exercise doesn’t have to be hard. It doesn’t have to involve a trainer. It’s just moving more in your day. You know, we all have technology now to hold us accountable to how many steps we’re taking, like a watch or a phone or something like that. You know, so, we take that at the core. And then everything else builds upon that. So, the medications, as I said, they decrease your appetite. They make you feel not hungry. And we’re seeing pretty significant, in fact, with Mounjaro, we’re almost seeing weight loss similar to surgery. Okay. And then so with surgery, people will lose 50 to 75% of their excess weight. And I think the biggest difference with surgery is its durability. And we now have 25 year data showing that the surgery is effective. It increases people’s lifespan. It increases their quality of life. It decreases their comorbidities like diabetes, high blood pressure, all of these other things that people suffer as a result of their weight.

Now, if we take it back to medications, and that concept that we talked about at the beginning that obesity is a disease. Hey, remember obesity is a disease just like high blood pressure, like diabetes. And if we tell people to take their blood pressure medicines, do we say try it for three months and then, oh, your blood pressure’s back down to normal, that’s great, you can stop your blood pressure medicine now. That’s not the conversation we have, right? Your doctor puts you on high blood pressure medicine. You’re kind of like, okay, well, I guess I got to deal with this for the rest of my life, unless you have obesity and you lose weight and can get rid of that comorbidity. But with weight loss medicines, and obesity is a disease, we tell them you’re allowed to take it for three months, like I said, for the Fen-phen or, youknow, these medications, people might get them approved through their insurer for a month or two months, three months, but they’re not thought of as lifelong medications.

And this is where I think the medications can truly be a game changer if we change that thinking that this is a lifelong effort, that not only do we want to help people lose the weight, but we also want them to help maintain that weight loss for a lifetime. So, that durability piece is what separates surgery from every other weight loss method.

The other thing that I did mention were the endoscopic techniques for weight loss. And these are things like balloons. These have been FDA approved for about four years now in the United States for placing balloons as space fillers within the stomach to help people eat less food; and therefore, they lose weight. They stay in for about six months for most of the balloons that are FDA approved currently. And then endoscopic sleeve gastrectomy is the newest player on that market. And this is very similar to the sleeve that we do surgically where we remove 80 to 90% of the stomach and tubularize it from the size of an NFL football to the size of a medium banana.

Well, now we can do this through the mouth, and we have devices that we place through the mouth, no incisions, that can collapse the front wall and the back wall of the stomach leaving the opening in the stomach being similar to the size of a sleeve. And this was just FDA approved with a device, which is huge for this to have an FDA approval for this particular procedure, where we’re seeing some weight loss similar to some surgical interventions in the short term. What we don’t know about these endoscopic procedures is their durability and longevity. But again, we have a lot of weight loss methods out there. And everybody’s got a different weight loss journey, and sometimes people have to try one and then try another or go from one to another to maintain that lifelong healthy lifestyle.

Pete Kenworthy
Before we move on…is there a specific time when you feel like you’ve tried diet and exercise, when it’s the time to move on to other options? Or is it like you’ve mentioned a couple times, everybody’s journey is different. Some people stop diet and exercise sooner than others, say.

Leena Khaitan MD, MPH
Yeah, so like I mentioned, diet and exercise are the core of everything. But yes, it’s hard, and most people will lose about 10 to 15 pounds over a year with diet and exercise alone. Okay. And so, if your body mass index, which is the measure we use to figure out how overweight people are, 18 to 25 is a normal BMI; 25 to 30 is overweight; anything over 30 is obese; anything over 40 is what we call severely obese or morbidly obese. And so, when you’re in that 25 to 28 range, you know, yes, diet and exercise is really the method that you want to use. Once your BMI gets higher and you start to develop other health conditions related to your weight, and really that’s where people really should think about that. You know, can you run around with your kids the way that you want to? Do you have to take medicines for your blood pressure, for diabetes? Do you have to wear a mask at night because you have sleep apnea? Do your knees hurt? Do your joints hurt?

You know, all of these things should make everyone think about how is my weight affecting those health issues? And the most amazing thing about weight loss…and I focus on surgery because that’s where we have most of the data, but we’re seeing similar effects from the weight loss also achieved with some of these medicines…is that when people lose the weight, those health problems go away. So, I can’t tell you how much data is out there telling people that, you know, after they lose the weight that their health costs go down, their time off work goes down. So, when should you seek an intervention? When your weight affects the way you live and your ability to do what you want to do every day and makes you take medicines or access the healthcare system that you probably didn’t have to before.

Macie Jepson
You’re a bariatric specialist, and I’m guessing that not every primary care physician knows what you know. So, where does that conversation begin for someone who says, I need help, and then how do they go about finding it?

Leena Khaitan MD, MPH
Yeah, this is a very, very hard conversation to have. Obesity has a lot of stigma with it, and a lot of physicians, honestly, are not even comfortable talking to their patients about it. Patients don’t want to hear that they’re overweight. They don’t want to hear that their weight is affecting their health problems. But if they’re told you have diabetes, take this medicine; you have high blood pressure, take this medicine, then people are like, yes, yes, yes. But if the doctor starts the conversation with, you’re overweight, for a lot of patients, they just turn that off, right? So, I think, you know, the conversation starts with every healthcare provider, because pretty much there’s no doctor that you’re going to see for anything where the disease that they’re treating is not affected by your weight. It doesn’t matter whether you’re trying to get pregnant, whether you’re seeing an orthopod for a knee replacement, whether you’re going to the cardiologist because you have heart disease, you know, weight is a part of the conversation. And in fact, if you go to the society guidelines on all those specialties, they even say that weight has to be a part of that conversation.

Now, like I said, the primary cares have a tough time because they have a limited time for a conversation in the office, and they can tell you, this is your BMI, or you need to lose weight. And they say you need to lose some weight, by the way. You have high blood pressure, you have high cholesterol, and by the way, losing weight would be really good for you. You know, maybe you should think about exercising. And most people know they need to lose weight, but to have that conversation about what resources are available to them to help them lose weight is a long conversation. This is not a two minute conversation. And our healthcare providers are tasked with trying to deal with all those problems in a very short period of time.

So, this is where weight loss specialists come in, and so your primary cares really need to have resources to be able to send you to and have that conversation. And then patients also need to be willing to have that conversation as well. And it’s a two-way street. And so, when should you start? You know, as we said, when those problems are happening, but if you’re not ready to have the conversation, then it’s not the right time to start. Because if you’re not ready to take accountability, you’re not going to make the changes and you’re going to think about everything as a diet. And yeah, I did that diet for a week, I lost weight, then it stopped working, and I just put it all back on. You know, but we all need to think about everything as this is just how I live, you know. I’m not going to eat rice, bread and pasta every day. I’m not going to eat fast food every night for dinner. You know, just change how we live. That’s the place to start.

And then our healthcare providers need to, I think, to have the conversation for healthcare providers to start with, you know, you do have high blood pressure, you have diabetes, but did you realize that your body mass index is 35? Does that mean anything to you? And a lot of patients will say, no, I don’t know what that means. Then taking that minute to say, well, this is what this means, and do you know that if your body mass index came down below 30 and better yet closer to 25, that you might not have to take this medicine anymore. You might not have to use that machine at night. You know, just starting that conversation and putting that thought in somebody’s mind is where the conversation starts. And then becoming aware of all the resources available to you. And not only do we have resources in the hospital, but then you got Weight Watchers, you got Jenny Craig, you got Noom, you got GOLO. I mean, the resources are endless, but taking that first step is the hardest part.

Pete Kenworthy
You talk about all these ways that people choose to lose weight and the bottom’s the diet and exercise pills, endoscopic surgery. But I want to ask you, too, about why people fail at each of these steps. You know, you mentioned in that last little part, you talked about Noom, which a couple years ago I lost 25 pounds and I did it through Noom. And so, since then people have come up to me, oh my gosh, tell me about Noom. And what I repeatedly tell people is it wasn’t Noom. That wasn’t the reason I lost the weight. I lost the weight because I was ready to lose weight, right, and I had developed this dry cough, and I was like, what is that? And my doctor said, lose some weight. And the cough went away in the first 10 pounds, and it’s never come back. I had tried many times before that, and I don’t honestly know why I failed before that, right? Maybe because I didn’t have any other issues popping up. And once I did, that was it. I talked way too long. Explain to me why people fail at various efforts.

Leena Khaitan MD, MPH
Yeah, you know, I think people, first of all, need to not flog themselves thinking that they failed because the minute you start to do that, it becomes a self-deprecating exercise, and you can never get to that place of progress. And so, you know, you have to have the right mindset as a patient, or not even as a patient, just as a person to say, you know what? I want to be healthier. I want to be a better version of myself. And as you said, Noom worked for you, but Noom has no magic to it. It’s not a medicine. It’s not, you know, any magic formula that they throw your way. What do they do? They make you think differently about your life and what food means to you, and that is how these work. And so, what has kept the Noom successful for you is because you embraced those concepts that it introduced to you and changed how you think about food and what it does for your daily life. And you’ve been able to maintain that as just how you live.

Now, if you said, I’m just going to think that way while I’m doing Noom and I’m hitting the button and it’s holding me accountable, then that’s where all these diets fail because they’re diets; they’re not how you live. And so, all of them have success rates, and I think that that’s why all of these different weight loss methods are out there because every person has to figure out which is going to be the best for them. None of them is wrong. None of them is right. What I will tell you is that when you hit that BMI over 35, over 40, that is where you really want to get serious because you are decreasing your lifespan when your BMI hits that range. And that’s where you really need to say, okay, this is not good, whether you have comorbidities or not because you’re decreasing the quality of your life. You’re decreasing your lifespan. And if you lose the weight, we do have data showing that if you lose weight, okay, and this is all based on bariatric surgery data, that you will live longer, you know. And so, if you want to live a longer, fuller, healthier life, then think about getting back down to a healthier weight.

Macie Jepson
Let’s go back to the pills for just a moment. Weight Watchers is buying into some of that. They’re going to offer that with their program.

Leena Khaitan MD, MPH
Yes.

Macie Jepson
Another, I saw a headline recently, another weight loss system is grappling with bankruptcy. Are these pills going to change the landscape of weight loss? Will you be out of business one day?

Leena Khaitan MD, MPH
Well, so I don’t think I’m going to be out of business. All right. Let’s look at the scope of the problem. Okay. If we look at the United States, a third of America is obese. If we look at Ohio alone, 39% of Ohio is obese. All right? We are doing about 300,000 weight loss procedures across the country right now per year. And if you put that in context of the entire population, maybe 1% of the population that qualifies for surgery is losing weight. But you know what? Surgery is a big step for a lot of people. Okay. It’s pretty scary to have an operation to lose weight, and, you know, it takes a lot from the inside for people to get there. And so I don’t think medicines are going to replace surgery. But, one, I think medicines are going to increase the number of people who are actually seeking weight loss because it’s a lot easier to take a pill or even give yourself a shot than it is to have an operation.

And so, it’s going to increase the number of people who are getting healthier, which is going to help us as a population. It’s going to decrease our costs in healthcare. It’s going to improve our outcomes with all of the other health problems related to weight because hopefully we’ll see less of those. Or if you do get a knee replacement, hopefully you’ll be more successful because you’re going to be at a lower weight when you have that knee replacement, for example. And so, it’s going to work out a lot better for you. So, I think that the weight loss medications, absolutely 150% are changing the landscape, and we need to improve the accessibility. The endoscopic procedures also give people another step between diet and exercise and surgery. So, that also has been changed in the landscape for the last decade. So, I think that, you know, all of these things has changed the mindset of Americans that we do need to be healthier so that we can dispel that progression of obesity that’s happening right now and the predictions that by 2030 that 50% of America will be obese. We need to turn that around.

Pete Kenworthy
You have covered a ton of stuff here today. Wondering if you have a way to tie a bow on it, wrap it all up. Any final thoughts you have?

Leena Khaitan MD, MPH
Sure. I think that the take home message for people should be that you have a lot of options to be healthier. And it starts with you in your heart and in your head, and you want to make sure that you want to be healthier. And then there are a lot of tools available to you, so you don’t have to go it alone. You have options, whether it’s diet and exercise. There are dieticians who can help you with that. You know, can do a lot of online types of things. You can get apps on your phone. If you’re looking to use medications, there are a lot of providers who can help you with that. There are endoscopic procedures, there are surgeries. You got to figure out what your journey’s going to be, what’s going to work for you, what health problems can improve. And the real take home is you’re not alone. You have a lot of partners in this journey, and everyone wants to help you be healthier.

Pete Kenworthy
Dr. Leena Khaitan, a bariatric surgeon at University Hospitals in Cleveland, thank you so much for joining us.

Leena Khaitan MD, MPH
Thanks for the opportunity. Great to talk to you today.