Announcer: 0:12

And now from the Blue Ridge PBS Studios in Roanoke, Virginia. It's the Virginians of Interest Podcast, with your hosts Brian Campbell and Carthan Currin.

Brian Campbell: 0:23

Hello I'm Brian Campbell and welcome to the Virginians of Interest Podcast. My friend, Carthan Currin can't be with us today because of a scheduling conflict. We're really happy today to have a special guest with us who's joining us from Richmond, Dr. Sue Wolver, who's an associate professor of internal medicine and the director of the VCU. I call it the Weight Loss Clinic. I don't know if it's the weight loss division there, so welcome, Dr. Wolver. You've got a really interesting background. We're going to get into a lot of things related to obesity today, but tell us a little bit about your background and what you did once you became a physician. I know you had some military experience and everything that brought you up to where you are today at VCU.

Dr. Susan Wolver: 1:00

Sure. Well, first of all, thank you so much for having me. It's a delight to be here and an honor to be here. Actually, I do want to say my disclaimer is that anything I do say in this podcast are my own opinions and that not from Virginia Commonwealth University's opinions. So a little bit about myself.

Dr. Susan Wolver: 1:19

Well, I grew up in New York and actually never liked living there and wound up transferring from a state school in New York to Virginia Tech. So that was my first foray into being in Virginia, love Virginia, and decided to go to medical school after majoring in biochemistry and when I looked at the price tag I decided to join the military to help them help defray the costs of that. So I joined the US Air Force and went to medical school at what was then called Bowman Gray, now called Wakefarr School of Medicine in North Carolina. After I graduated from there, I did an internship in the military and then went to flight surgeon school and became a Air Force flight surgeon.

Dr. Susan Wolver: 2:10

Most people don't really know what that means. They think that means you actually do surgery in the air, but that's not really true. It's really just a primary care doctor that takes care of pilots and their families. But I was also required to actually fly with my squadron four hours each month, and my very first assignment was again back here in Virginia at Langley Air Force Base, and I was with the first fighter squadron of F-15s, and I was there about a month and got deployed to Saudi Arabia for Desert Storm. At that point in time, of course, all fighter pilots were male and so I was a female fighter—I was a female flight surgeon with a whole squadron of male fighter pilots in Saudi Arabia during Desert Storm.

Dr. Susan Wolver: 3:00

After that, I married my husband, who is a fighter pilot, now retired and we lived kind of all over the world and I always wanted to get back to Virginia and so it came time for him to retire and me to go back to training. And so I came back here to Virginia and trained at VCU in internal medicine and have stayed on since. So I've now been here 20 years at VCU.

Brian Campbell: 3:30

Well, that's a really terrific background, but how did you get interested in, specifically in obesity medicine as part of that story?

Dr. Susan Wolver: 3:39

I started in primary care.

Dr. Susan Wolver: 3:41

And in primary care, you may know, we deal with a lot of chronic diseases diabetes and high blood pressure and heart disease and heart failure and arthritis. And year after year after year, I would tweak medications, keep adding medications, keep adding medications and nobody ever got healthier. And I would always talk about diet and lifestyle. Nobody ever lost weight. And it wasn't until I got to be middle aged and I realized that, following the same advice I had been giving to my patients now for decades, I started gaining weight. And the harder I tried to lose weight, the more I gained, and that's when I kind of had my epiphany and.

Dr. Susan Wolver: 4:26

I realized maybe it's not that my patients aren't following my advice.

Dr. Susan Wolver: 4:30

Maybe my advice is wrong. So I set out on my own personal journey to figure out how to lose weight. I was able to find the low carb way of eating effortlessly, for the first time in my life, lose 15 pounds, which may not seem like a lot, but had I not made an intervention at that time, which was about 12 years ago now, I probably have 40 pounds to lose. I was so successful and it seemed so easy, I thought I'd try it with a few patients, and actually it worked for them as well. People were able to reduce their medications, feel better In a short period of time.

Dr. Susan Wolver: 5:03

I felt more successful than I had in the decades prior, and so I thought, well, I really need to get myself trained now. And so I got no training, zero. Not one minute of training in nutrition in medical school or residency, and so I figured I had to get myself trained. So I got board certified in obesity medicine, for I've been running the VCU medical weight loss clinic now for 10 years, and for the first five years I continued my primary care practice and my obesity practice and over the last five years actually offloaded my primary care practice and now practice obesity medicine full time and have two wonderful associates that work with me and actually an entire multidisciplinary team.

Brian Campbell: 5:51

What? How difficult was it? Because I know there's a physician shortage right and that we have a big problem not just in primary care but in specialty care. How difficult was it to get that training later in your career, and is it still? Is that training accessible to other physicians that may want to do what you did?

Dr. Susan Wolver: 6:08

So that's a really great question. Right now, obesity medicine is not recognized as a subspecialty the way pulmonary medicine, cardiovascular medicine, rheumatology, things like that are. It is a continuing medical education pathway and that's actually the way a lot of different subspecialties start, like addiction medicine, palliative care, where it's sort of a grassroots we know we need this and then people put together some training and then there's some kind of test and eventually that will lead to actual fellowships and sometimes actual subspecialty designation, so anybody can do it actually. In fact, the people sitting for the board certification exam in obesity medicine has been skyrocketing over the last decade, literally exponentially skyrocketing.

Dr. Susan Wolver: 7:08

To me is the most fun I have ever had in medicine. Every single day I feel like I cure cancer. To me, obesity is like a cancer. It actually invades every facet of a patient's life, things that you wouldn't even think about. One of the things we do when people come to see us is we always ask for what we call non-scale victories. Patients are always focused on the number of the scale, but to me, weight loss is actually a side effect of taking care of yourself and learning where are the nutritious foods and how to eat them, how to move your body around how to manage your stress, how to get better sleep, and when you take care of all of those things. Weight loss is a byproduct of that.

Brian Campbell: 7:55

First of all, let me ask two questions what's the state of obesity in America and Virginia? I presume they're probably about the same and the second of how do we get here? It just seems to me that I saw one number that it said 40% of Americans are obese, and that's a much more dramatic number than it would have been 20, 30, 40, 50 years ago. So is that a byproduct of one the way we behave and then also our food or what is the primary driver of this epidemic?

Dr. Susan Wolver: 8:22

So I'll start with, I guess, the second question.

Announcer: 8:24

First, or maybe it was the first question, I don't remember.

Dr. Susan Wolver: 8:26

What is the state of obesity in Virginia, and you said that it's probably the same as the rest of the country and actually it's not the Southeast, and the South and Southeast actually has the highest rates of obesity in the entire country. And I don't know if you ever have links within the podcast, but it would be great to link to the CDC obesity maps, because pictures speak a thousand words, and so Virginia is significantly higher. And then also when you look at the different demographics, african Americans have a 46.7% rate of obesity in the Commonwealth, which is astronomical. That's nearly half of the Commonwealth.

Brian Campbell: 9:17

Well, that leads me to my next one. But so how did we get here? Is it just? I know there's a food problem and there's also a behavioral problem with us not having the same lifestyle. Is that really the two big pillars of this thing?

Dr. Susan Wolver: 9:30

So everybody kind of has their own slant as to how they think we got here. I will tell you mine. I really think that there's a very definitive time and again the CDC obesity maps will really show you how obesity has marched through the decades, really starting around 1980 when we came out with that very first food pyramid. I don't know if you remember it, but it said eat the majority of your diet from starch, bread, rice, pasta, cereal. Where did that come from? It actually came from a man by the name of Ansel Keys.

Dr. Susan Wolver: 10:07

He was a physiologist who lived all over the world and he looked to see what people ate and what their risk of dying from heart disease was, and he found something that he thought was very interesting. It looked like people who ate more saturated fat had a higher rate of dying from heart disease. However, what he did was something we call an observational study. Observational studies can only show correlation, they can't show causation. I'll give you a quick example of that, if you see a little tiny kitten sitting in a roof that has caved in.

Dr. Susan Wolver: 10:44

Did the kitten make the roof cave in or did the kitten crawl up on top of the roof that happened to be caved in? So that's the difference between correlation and causation. So he did his studies and he published something called the Seven Countries Study. That looked like there was a straight line between how much saturated fat you ate and your risk of dying from heart disease. But there were really two problems, so actually three. The first was it was correlation, not causation. The second problem was there were actually a lot of countries it was actually a 22 country study, not a seven country study and there were many countries that actually ate a lot of saturated fat and didn't have increased risks of dying from heart disease. And he left those out of the study. And when you add those back in there is not even what looks like a correlation. He was also a real big bully. There were people at the time that said you know, that's a very interesting observation and now we should do some studies to see what happens when we take the fat out of the food.

Announcer: 11:46

And he said you know we really don't have the time to do those kinds of things.

Dr. Susan Wolver: 11:50

We just really need to get the fat out of the food, and so we actually went to our government and the McGovern task force put together our very first dietary guidelines, which were published in 1980 with that food pyramid. Which was heavy Some that said it was sugar, and they were really silenced. In fact, there's some evidence that people at prominent institutions were actually paid money to say that fat was the enemy and not sugar.

Brian Campbell: 12:18

Well, back to the food pyramid, so back to the basis of it. It sounded like a very car eccentric base, right, there's a lot of carbohydrates and everybody thought we'd just get rid of the fat and go with the carbohydrates. But that has actually not worked in our advantage, correct?

Dr. Susan Wolver: 12:33

Exactly. One of the reasons for that is not only the carbohydrates themselves, but when you take the fat out of the food, most of the time it tastes worse, and so you have to put something to make it more palatable, and that is sugar. And so we eat so much more sugar than we ever ate before, not only in the things that you know have sugar, like ice cream and cake and cookies, but food companies put sugar in practically 80% of the foods that we eat Things that you never think should hurt Sugar, like dogs and coleslaw, and things that would be surprising to you that actually have sugar. And then many of the foods that we eat are so processed that they turn to sugar in our bodies. People don't realize that starch are just a bunch of sugars holding hands, and when we eat it they let go. And so, even though bread tastes differently to you from ice cream, in your body they do basically the same thing.

Brian Campbell: 13:32

So I guess this has always been a problem too Just me as a general consumer of being interested in this topic. There's been all the fat, the diets right, there's this diet and that diet and the Atkins diet and it does seem to be now this idea that the culprit really is more carbohydrate and sugar-based that Atkins was sort of at least heading in the right direction. What did Atkins? This is all our opinion, yours and mine, not indicative of any professional thing. What did Atkins get wrong? But just, is there something related to getting away from carbohydrates where they should just eat meat, or is it more complex than that?

Dr. Susan Wolver: 14:10

I don't think Atkins got anything wrong. Actually, he was actually right on the money. It was just such a paradigm shift at the time that people weren't ready to hear it, so we've really kind of gone back to many of us thinking that that is a much better way of eating.

Dr. Susan Wolver: 14:30

One of the issues with figuring out what is the proper human nutrition, which is a little bit different from dieting, which we can talk about in a minute but one of the things is Is it carbohydrates? Is it processed carbohydrates? What really is it? That is the problem. You always have to look at what you're eating and compare it to what we call the standard American diet, which is essentially the food pyramid, which is essentially 50 percent of your diet is from carbohydrates. But even our whole grains are much more processed than they were many, many years ago, decades ago.

Dr. Susan Wolver: 15:13

So over the last 40 years, I told you that we didn't do the experiment that people asked to do. Back when Ansel Keys made his initial statements and published his initial study, people said we should do studies to see what happens when we take the fat out of the foods. Do people get healthier? And we've actually all been a part of those experiments for the past 40 years, whether we wanted to or not, and we know that the health of the nation has gotten dramatically worse. You know, right now, three quarters of our nation have overweight or obesity. One out of two people has diabetes or pre-diabetes. In fact, we call it diabetes because they're just so unbelievably linked. Do you know that about 120 years ago, type two diabetes barely existed? If you were a physician and you had someone with type two diabetes, you'd probably call all your colleagues to come in and see this patient who has this disease that we just almost never see. And now we all either have diabetes or pretty much know someone who does.

Brian Campbell: 16:21

Yeah, that gets back to another question. That back to the way. It is a perception. I've read recently this idea that it's the last form of acceptable discrimination that somebody sees someone who's obese or needs to lose some weight and the first thing is, oh well, they like this one, they're not, it's their fault for this. But now we're beginning to realize, by teasing this out, that there is a little bit of a conspiracy here. There's a conspiracy to get people fat and to keep them fat. Is that not correct?

Dr. Susan Wolver: 16:48

Well, I don't know if I would say it's. You just kind of have two things in that sentence. So the first one is their bias, and I absolutely, wholeheartedly agree that there is bias. There is bias by everybody, there's bias by the medical institution, there's bias by friends, family, everybody thinking that this is a disease of willpower. And the more and more we learn about obesity, and especially the more I learn about obesity, it becomes a increasingly complex disease with many, many factors, food being, I think, the start of the whole thing. We started eating foods that are hyper-palatable, very processed, high chemical content, and they actually have food scientists that sit behind closed doors to figure out how to make these foods as palatable as possible, putting as much sugar in without it being too sweet. They actually have a name for it.

Dr. Susan Wolver: 17:55

It's called the Bliss Point. How much sugar can you put in a food item and make it more palatable without it being too sweet? And so they're figuring out ways to make us want to buy more of their foods. When we eat these very processed, high carbohydrate foods, it makes our blood sugar go up, even if we don't have diabetes, and then insulin comes on board to help our body manage that blood sugar. It drops our blood sugar, so then it makes us hungry and crave for more.

Dr. Susan Wolver: 18:29

So the thing is, we're actually fighting against our biological drives that were here to keep us surviving when we didn't have a 7-Eleven on every corner and fast food you know, three fast food restaurants in one block. So our biological mechanisms, which were meant to protect us and keep us surviving, actually work against us now. When you lose weight, your body will fight you tooth and nail to regain that weight, so you will get increasingly hungry and you will decrease your metabolism. So that is oftentimes why people lose weight, only to regain it again and get back to their set point, where they were before. Now I don't know if you have more questions, but you had a second thing about the conspiracy theory, so maybe you want to ask questions and we can go back to the consensus.

Brian Campbell: 19:22

Well, yeah, and then I'm going to move on a little bit to just how do you treat patients. But I guess I never really thought about it before. But you know my parents, who were born during the Depression. You know almost all the food they consumed was around them. They had gardens, they had animals. They you know sort of it came from where they did.

Brian Campbell: 19:37

Now this supply chain is everything is processed and stuff is added to it. So back to the idea again, is that part of the deck is stacked against people. Whether it's a conspiracy or not is probably for another show, but the deck is certainly stacked against people who do have the desire to lose weight, because it's intentionally stacked to try to keep you consuming products. Yeah, well, I mean, that's a good place to move on. One of the things that in researching before you came on the show, it just doesn't seem like there's a lot of people that do what you do Particularly. Let's keep it just to Virginia here. How many? I mean, is there a number you can give me? How many obesity doctors are there across Virginia? Are there other multiple clinics other than just at VCU?

Dr. Susan Wolver: 20:21

Oh, sure, yeah, and, like I said, the number of people getting board certified in obesity medicine is skyrocketing.

Announcer: 20:28

So there are a number of people right in Richmond that do obesity medicine.

Dr. Susan Wolver: 20:32

You know some do it through the organization that I went through. You don't have to actually be board certified. In fact, I know that we're going to talk a little bit more about primary care doctors managing obesity and, quite frankly, with two thirds of the nation having overweight or obesity there are there will never be enough of us to go around. So we do need to work on educating primary care doctors as to how to treat obesity both safely and effectively.

Dr. Susan Wolver: 21:04

And I tried that for years when I was a primary care doctor but I didn't get the proper training and, quite frankly, there's good evidence that shows that most primary care doctors until recently had really given up talking even about weight because we had been so unsuccessful in treating it. We didn't have the right knowledge, we, I think, didn't give the right advice and we actually didn't have great medicines and we didn't have great tools to help us help patients to actually achieve weight loss and improve metabolic health.

Brian Campbell: 21:39

Well, that's a good question. So you've just been doing this 10 years, so I can't pick up a paper today without having something in it about all these new category of drugs which are just having a tremendous positive impact on that. How was your practice 10 years ago versus where it is today in terms of tools in your toolkit?

Dr. Susan Wolver: 21:56

That's such a great question. I mean, I was just watching the news earlier and now there's a new label morning that we can talk about specifically if you want. But you're right, you cannot watch TV today or listen to the news, I think, on a daily basis and not hear something about the new injection medications. But we've actually had medications to treat obesity since the 1950s. The very first drug was Fendramine, which is a ovaritite suppressant, a little bit of a stimulant. And it's interesting because obesity medicines have been in the news a lot, because you can remember probably FenFen I don't know if you remember that. It was a wildly successful medication but then turned out that one of the components actually could cause damage to heart valves, so FenFen was removed. But the Fendramine of the FenFen was actually not the causative problem, so that's been on the market for a very, very long time. In the past decade we saw a couple of new medications. I'm not going to probably talk about brand names, but they had some efficacy, some of them were successful One of them.

Dr. Susan Wolver: 23:07

that was what I thought more successful was actually also removed from the market. There's very little appetite for keeping obesity medicines on the market that can cause problems, especially that weren't all that effective. So until about three years ago, the majority of my and the vast majority of my patients were not on medications for weight loss and they weren't able to be successful. But it really requires a great amount of effort and attention to lifestyle, to what you eat, exercising. But, most important, I always say weight loss is less about what you eat and more about how you think. I say weight loss happens from the nose up. It has to do with how you mindfulness and how you think about your foods, how you behave, your behaviors. So that's really and your relationship with food. Those are really the most important thing mindset, behaviors and your relationship with food.

Dr. Susan Wolver: 24:18

But enter three years ago and we started to get this class of medications called GLP-1s leucagon-like peptide-1 agonist medications. They started actually for diabetes and they noticed that people who were taking these for diabetes started losing weight. So some of them have been rebranded and FDA approved now for weight loss alone and they are coming out fast and furious and each new genre of this medication is actually more effective than the one before, and we have some in the pipeline right now that are really approaching how much weight you can be expected to lose with weight loss surgery. So I really feel like my toolkit has expanded dramatically, so-.

Brian Campbell: 25:10

Well, let me tell you and I think I may have mentioned this to you before that the Wall Street Journal, which is not a scientific journal but it's an interesting journal, did a story, probably three months ago, about the collision of two types of research. One was on Gila Monsters, which I guess only eat four times a year, and the other is this thing called the anglerfish, which is this really ugly fish that live in the Atlantic Ocean, and it gets back to the discovery of GOP-1, that there were these two bodies of research around. The way that you're the scientist, not me, but the way that all this happens, and it was the collision of those two that led to you're right, the diabetes drug, but the weight loss occurred because it also can you help understand the doesn't part of an interview with a brain transmission too? One, the way your stomach empties, but then also the satiation, the fact that you're feeling fuller and don't have the desirity.

Dr. Susan Wolver: 26:02

These medications do a number of really great things, so certainly they reduce that, so they're actually GLP-1 is actually a normal hormonal peptide in your gut, and what the GLP-1 agnus are doing is they're really keeping that GLP-1 around longer, and so you're having more of an effect of something that is naturally there, and what this GLP-1 does is it slows the movement of food throughout your body. Thereby it keeps you fuller, larger. You feel much more full, but you also seem to have many less cravings, and part of that is gut related and part of that is brain related.

Dr. Susan Wolver: 26:48

One of the things people say and I actually just saw it published just the other day is it really quiets the food noise in my head. There are people that have a number of different kinds of eating disorders, like binge eating disorder, but people who are just so hooked on the processed food that all they can do is think about food all day long. And they say now their brain is freed up and they can think about other things. They're not eating and thinking when am I getting my next meal? When am I getting my next snack? They're not going to bed thinking about breakfast the next day.

Dr. Susan Wolver: 27:23

It is incredibly distracting to be thinking about food all day long, and some people do that and unfortunately, oftentimes people who need to, who have weight to lose, are the ones thinking about food all day long. And if you wanna lose weight, what you wanna do is think about food less, and these medications absolutely help you to think about food less. Now the other thing a couple of weeks ago, we found out that the latest study shows that one of these medications actually does help to prevent cardiovascular events. So it's a definite benefit for cardiovascular health. There's also great for liver health. So there are many things that these medications do other than just help people lose weight. They are really terrific medications but, yes, they do have side effects, as does any effective medication that helps people with any of the other many chronic medical conditions we see.

Brian Campbell: 28:26

Well, I remember reading, probably five or 10 years ago there was this theory that the gut was the holy grail of overall health, and I read something today that was related to a motor disease like Parkinson's and so forth. There's some science that's beginning to show that a lot of that activity potentially is in your gut. So was this discovery in the GOP one? It's really a gut discovery, correct? I mean, it's a hormone that's in your gut that affects your ability to your brain and your food and how you process it correct.

Dr. Susan Wolver: 28:55

Yeah, we've known for a while now that the gut and brain axis is very robust. I mean, think about it when you see something horrifying, do you ever feel like you were kicked in your stomach? Yep, right. So we know for sure that the neurons definitely have some connection between the brain and the gut. But the whole other study of gut stuff is really the microbiome.

Dr. Susan Wolver: 29:19

That's really where the trendy research is now all the little bacteria the good bacteria and bad bacteria that live in your gut and how medications you take, foods you eat, everything that you do affects the populations of the bacteria that are living there and they're even looking at things. Well, what if we take somebody else who's thin and take their bacteria and put them in somebody who needs to lose weight? They're working on those kinds of things in mice and we actually do have some application of actually taking somebody else's feces who's healthy and putting them into somebody who is unhealthy and re because they have a particular disorder, and repopulating the healthy bacteria and making that person better. So there's a lot around the gut microbiome these days.

Brian Campbell: 30:10

The gut is the holy grail. Well, with all the positives, but the stuff with all these drugs that we're not gonna use brand names, but that they exist, there's a downside, and the downside is one is cost. The pharmaceutical companies wanna recover their costs for all the research and discovery. So one they're expensive. And number two probably a year or two ago I guess they called the Hollywood effect, right that I forget one of the celebrities who's an influencer on Pinterest or whatever they call it. So now there's this rush for people who may not even meet some of the clinical definitions of obesity, who just wanna get ready for the wedding dress or tuxedo or whatever. So explain how the cost of these medicines and accessibility has influenced your practice.

Dr. Susan Wolver: 30:58

So I'm noticing you love to ask two questions at once.

Dr. Susan Wolver: 31:01

Sorry about that, so first I'll go so I'm writing them down now because there was one question way back that I wanted to pay more attention to and we'll get back to that because that kind of will play into the second question. So the first one was the expense of these medications. Absolutely, these medications, without any kind of insurance or anything, are about $1,200 a month. So very, very expensive medications. And here's something that a lot of people do not know these are pretty much long-term medications. These are not medications where you're on them for three, six months a year. You get to your desired weight and you stop them. We have great studies that show when you stop these medications you get weight regain. So when people go on these medications they really need to know that they're long-term medications.

Dr. Susan Wolver: 31:51

However, when we treat people with these medications, oftentimes we can dramatically improve or reverse many of their other chronic problems like diabetes, high blood pressure. I routinely take people off with both diet, not medication alone. You have to do lifestyle too, but with changing what people eat and the addition of these medications. I've taken people off of hundreds and hundreds of units of insulin and their A1Cs have normalized. That's the number that we look at to see what their three month blood sugar levels have been. People have come off their blood pressure medicines. People have come off of CPAP for sleep apnea. I have people who are on disability who are now working full-time jobs.

Dr. Susan Wolver: 32:39

So when you look at expense you can't just look at how much that medication costs in a vacuum. There's so much downstream benefit to the individual and to society to making this person a more productive member of society. Now there are going to be a couple of things that I think are going to help. First of all, more and more insurances are covering these medications. We were very fortunate in Virginia that Medicaid as of January started covering these medications. The federal government in January started covering these medications. So I think there are more entities that are seeing the downstream benefit. We do have a bill in Congress called TROA Treat Obesity Act and has actually been in Congress for 10 years and has not been passed.

Dr. Susan Wolver: 33:39

But it is to help obesity be treated in the Medicare population and hopefully this year it's getting more traction than it's gotten before and will be passed so that we can get not only obesity treatment for the Medicare population but the obesity medications which are a real pillar of obesity treatment. So we're hoping that we'll get more coverage and then we're hoping, with the addition of more medications, the prices will go down because there will be more competition and hopefully next year we will have the very first generic GLP-1. So one of the initial GLP-1s will be going generic next year. So hopefully this is going to put a lot of price pressure on reducing the cost of these medications.

Dr. Susan Wolver: 34:30

However, there is another major issue and I'm sure some people listening to this podcast right now are actually throwing things because the availability right now is zero. I have zero ability to start anybody on either of these GLP-1s that are made for weight loss right now, and even the ones for diabetes, because people are using them off-label for weight loss appropriately. So I'm not saying that it's inappropriate. There's almost no supply right now and people who I've started I now have to stop and I told you what happens when you stop these medications there's weight regain.

Dr. Susan Wolver: 35:11

So it's a really challenging time I got to tell you in the last year, the pendulum has swung so many times with these medications. So that brings me to the second part, the Hollywood part. So, prior to all the news and all the buzz of these medications, I found myself really having to try to convince people that this might be an appropriate addition to our treatment of their weight, and I would get a lot of pushback. Who wants to inject themselves with a needle? And I would have to explain to them all the benefits that I thought they could possibly get for them to consider trying this medication. Then, when everyone went Hollywood with this medication, people were actually knocking down my doors to get this medication, demanding the medication, and I only add the medication if I think it's an appropriate addition to the regimen that they are already working on.

Dr. Susan Wolver: 36:12

There are plenty of people who can do just fine with getting very educated about the foods that are going to be healthier for them and the foods that are making them hold on to weight, how to safely exercise and really change their life without medications. Plenty of people can do that and do that very, very successfully and even come off their other medications. So to have someone come in my office the very first day and be put on a medication, especially if they're demanding it now knowing this is a very long-term medication.

Dr. Susan Wolver: 36:42

Without knowing maybe they could have done it on their own just fine that that's not the way I treat my patients. So there's the people knocking down my doors, and then of late, people are talking about all the potential side effects, and today they're putting an additional warning that people can get intestinal blockages on this medication. There are a couple of people that are suing some of these companies because they got what's called gastroparesis, which is sort of a paralysis of your GI system, where food's just really not moving through your system at all and you have chronic nausea.

Dr. Susan Wolver: 37:17

And so now people are saying I don't know if I want to start this medicine again, or should I come off? Of this medication. So I mean, I'm getting whip-match from how quickly the tide is turning and of course it's all because of social media.

Dr. Susan Wolver: 37:32

Things just change on a dime. Without necessarily the evidence backing the change in public opinion, I do have to say that most people tolerate these medications very well. I think that we do need to help primary care doctors understand risk benefit with these medications and how to do them safely. If you're not asking the question, some patients have just stopped eating on these medications.

Dr. Susan Wolver: 37:58

That's very dangerous because they're probably losing muscle rather than fat, and so you have to know the questions to ask. And who's a candidate for these medications? There are some conditions where people wouldn't be a candidate, for instance, people wanting to try and have a baby in the next couple of months. You actually have to be off of these medications for a couple of months before even starting to try and conceive. So there's a lot of nuances with these medications, but overall they're fantastic medications. But that also brings me back to something we started talking about and then we got off track, and that was bias. I think that's so important to talk more about.

Dr. Susan Wolver: 38:37

Some of the problem with these medications is people think, oh, they shouldn't go on this medication, they should just work hard, they shouldn't have an easy way to get off for their weight and, as we mentioned, it is very difficult to lose weight and it is not a willpower issue at all. Like I said, it is a very complex hormonal disease with many, many, many hormones playing a role, many societal and lifestyle factors playing a role. So getting weight loss surgery is not an easy fix. Going on a weight loss medication is not an easy fix and despite what you do whether it be surgery or medication or changing your diet. You still have to work on the lifestyle piece, the mindset, the changing behaviors in the relationship with food.

Brian Campbell: 39:30

Well, it seems to me back to the supply chain thing that I also believe these are blockbuster things and I read a lot.

Brian Campbell: 39:40

It's nice for you to have these tools in your toolkit, because what we didn't talk about as much as the comorbidities, the diabetes, the healthcare, the people who are dying from being obese. So at least it's something else in the toolkit, but isn't part of the reason the supply chain that these are injectable biologics at the end of the day, which is one that makes them harder to manufacture and then harder to distribute because they have to be refrigerated, et cetera, et cetera. What do you think the next five or 10 years will bring? Don't you think now that there's been big change in this business? Don't you think that new drugs will be continuing, and is there ultimately going to be something in this category I think you just mentioned it whether there's going to be a generic? Will there be the ability not to have it be an injectable? Do you think we'll get to a better place where the supply chain will catch up with some of this?

Dr. Susan Wolver: 40:27

I think that unfortunately, there was this huge crux of these medications and COVID, so supply chain issues really happened everywhere, and so I think it was just really bad timing. I think also the drug companies really didn't realize the demand for these medications and of course, when I talk to them I say you just needed to ask me, because as I started using these medications, I realized what game-changing medications they really were. And so in the next five to 10 years, what I see is more and more drugs. We do know that one of the oral medications we do use now for obesity, at a higher dose, may actually have more efficacy. So they're looking at that. And, yes, I do think that they're looking at more oral medications. These medications are much more difficult to formulate orally. They degrade very fast and that's why the injectable was easier to put out. Quite frankly, right now the injectables have much more effectiveness than the oral formulations of the same medications, but they are, yes, rapidly in the pipeline.

Dr. Susan Wolver: 41:41

So right now we talked about this medication being what we call a GLP1 agonist, so promotes more GLP1. We now have a medication that is used to treat diabetes which actually has two peptides, glp1 and GIP, is being sought after FDA approval for weight loss alone, unbelievably successful. Now there is one in the pipeline that is still in study right now that is a triple peptide, glp1, gip and glucagon, which is even more effective. So, yes, I think we're going to see many, many more medications, both injectable and oral, come into the marketplace and, like I said, I hope that's going to put price pressure on the drug companies, on insurance companies, that we can actually safely use these, safely and affordably give these medications and use them in the appropriate circumstances.

Dr. Susan Wolver: 42:47

For a far wider swath. It's unfortunately the disparities of care, and people with lower socioeconomic income and accessibility to medical care and to medications are oftentimes the ones who need this the most. And, as you said, we didn't talk about the comorbidities of obesity, but diabetes, high blood pressure, arthritis of the knees and the hips, heart failure, atrial fibrillation. We know that obesity has about at least 60 chronic diseases and we know that obesity is a major risk factor in almost half of the cancers that we see.

Dr. Susan Wolver: 43:29

Wow, let's treat obesity effectively, we will have such success in treating, making great progress and maybe even reversing a lot of these additional complications of obesity.

Brian Campbell: 43:45

Now I'll tell the listeners. There's a great segment on 60 Minutes in the last year so, with Leslie Stahl on these drugs, and she interviewed two women One had been on the drug and lost a lot of weight and one whose insurance company would not pay for it. And as she was interviewing her, she told her and there was an emotional thing that the insurance company had agreed to it. So back to this idea that people have to be on these drugs longer. It's a risk benefit, right? So the risk if you keep the weight up are really pretty bad, and the side effects, which we could get into if you want to, but they're not nearly as bad as what you're going to face if you continue to have the weight. So, and is the other reason why it's okay to be on these more long term? You said earlier these are hormones that are essentially in your body. To begin with, you're just sort of ginning them up a little bit, and is that related to the side effect?

Dr. Susan Wolver: 44:32

Absolutely. Now I have to say we were using the medication for diabetes a lot longer, and in Europe even longer, so don't quote me but probably 15 or 20 years. At least one of them has been used for diabetes, but we don't know what's going to happen.

Dr. Susan Wolver: 44:50

If we have somebody who's 20 years old with obesity and wants to go on these medications, what's going to happen if they're on it for 50 years?

Dr. Susan Wolver: 44:59

We don't know the answer to those questions yet, but we also do know and this is something I have said for a very, very long time and especially in my teaching of medical residents is, in the history of treating obesity, we have always underestimated the severity of obesity and what obesity will cause the individual and society in terms of their own health and well-being and able to be a functioning member of society and all of the medical complications that they will have, and we have overestimated how dangerous treatments for obesity are.

Dr. Susan Wolver: 45:41

When I was coming through medical school and residency, what I was taught was yeah, you can go on a weight loss medication. It should probably only be for three months and, in fact, fentramin. If you read the product information that comes with it, it says it's used for only 12 weeks and then you have to remove it. However, it is actually part of a combination drug which is for long-term use. So go figure right, and it's been approved for long-term use. But so I was taught that if you go on these medications, you should only go on them for short term, and when you stop them the weight's going to come back anyway, so there's really no point in doing it anyway.

Dr. Susan Wolver: 46:21

Well, we don't put people on blood pressure medicine for three months and then take them off and see what happens. Right, we treat chronic diseases chronically and that's how we really have to look at obesity. We have to remove the bias as a society. You're absolutely right, it is one of the last places where bias is accepted.

Dr. Susan Wolver: 46:40

I mean, look at advertisements, look at TV, look at the medical institution it's saturated with bias. There's a very interesting study that shows a medical student talking to a. They're looking at an animated person who has a normal BMI, who is telling the medical student about all of their medical problems, and then the medical student has to say what they think the cause of the medical problems might be. And then they show the medical a different set of medical students. The exact same scenario, but the cartoon character has a BMI in the obesity range and what the medical student comes up with is completely different, because they attribute all the symptoms to the patient's weight.

Brian Campbell: 47:40

That's a.

Dr. Susan Wolver: 47:40

That's a don't come up with a bunch of other things that it couldn't be.

Brian Campbell: 47:44

Well, that's a good segue into your your clinic or the one that you run at VCU I used to work for at a medical school and the dean was just a terrific person, good friend, and he would try to describe how medicine was practiced different today than it was 50 years ago, and part of what he blamed it on, and I think he was accurate. He said we used to have relationships with our patients and now we get paid to do things to people. That the this idea of coding right that that insurance companies pay for, based upon the code. So so in some respects we've become a little bit of a manufacturing operation. We're people moving through the machines and we're doing things to them and the money follows, whatever the code is. It seems to me, based upon your relationships with your patients, you've turned it back to a little bit of the old model, that that that part of this isn't just accessing care, it's the relationship you have with your patients. Could you talk about that a little bit?

Dr. Susan Wolver: 48:31

Sure, you know I did. I practiced medicine now for 35 years and I feel like I do better primary care now than when I was doing primary care, because I really feel that people who are holding on to extra weight it's not just a food problem, it's an everything problem and everything matters. When medical students rotate with me, they're they're kind of shocked. They say, wow, this works really differently from all the other clinics because we look at everything. We look at their medical problems, we look at their sleep, we look at their stress levels, we look at who they live with. We look at how they can afford food. If I'm telling somebody to to markedly reduce the carbohydrates in their diet and they're getting their food from the food pantry, how's that going to work? We look at cultural sensitivities. If we have someone whose her cultural background is they eat a lot of rice and beans and I say, well, you got to stop eating rice and beans, how's that?

Dr. Susan Wolver: 49:28

going to work, so we really have to meet patients where they are and I feel so fortunate, in sort of the the tail end of my career in medicine, that I get to take all the things that I love about medicine and taking care of patients and preventive care and and helping people to regain their health and I feel like I'm able to do it more in obesity medicine than I was ever able to do it in anything before.

Dr. Susan Wolver: 49:58

And I feel so fortunate that VCU has has backed me in my crazy idea 10 years ago that I actually started with a few of my primary care patients in the file room that we had gone to electronic medical records and so we had no files there, just a big empty room and I I called a couple of my patients and we sat in the back room with a big flip chart and I scribbled some things with with markers and, and we've had probably a thousand iterations of our program at this point in time. But I love going to work every day. I finished the day feeling like I am inspired by my patients who have been through tremendous struggles and are taking their lives back, taking their health back, and it's such a privilege to to walk along that journey with the patients.

Brian Campbell: 50:49

Well, we clearly need more people like you. So, since we can't clone you, I'm going to give you the an unlimited budget, a federal state budget. How would you? And we're going to declare war on obesity. So what do you do in the next 10 years with an unlimited?

Dr. Susan Wolver: 51:03

budget. Oh my gosh, I love this. Do you have like three?

Dr. Susan Wolver: 51:06

hours now because I've got my plan and you know, unfortunately we got to work from both ends right. So I'm at the end with one patient in front of me. We're trying to get a little bit further by going to talk to primary care doctors so they feel more confident treating obesity, talking at churches and getting lay people to to buy in. We just started our own podcast actually to try and reach more people, but unfortunately that's going to be the, the, the tiny drip in, you know, the in the puddle, you know, with little tiny ripples. The other end we absolutely have to work on is policy right. When it costs less to get a two liter bottle of Coke and a Snickers bar than it does to get a piece of chicken and some vegetables, we're never going to win.

Dr. Susan Wolver: 52:11

When our food guidelines, our dietary guidelines, still tell us to eat half of our food from carbohydrates, when those food guidelines, the USDA guidelines, they trickle into everything, including what our children are eating in school. Oh my gosh, do you see what our children eat in school? When I first came to Virginia back in 2003, and my children were in elementary school, I wrote to the head of the Chesterfield County School Board and I said how are we feeding this to our children. I wouldn't ever bring this stuff into my house on a regular basis. They said well, we have to follow the dietary guidelines. They're eating pizza and chicken nuggets and french fries and ketchup as a vegetable, in fact. Again, if you can link out, I'm going to send you a link of something today that was in the magazine the Hill about a lunch lady talking about her experience having to feed this food to children and knowing that it's not right.

Dr. Susan Wolver: 53:21

We have to change policy at the highest of levels. We have to get farming back into communities, both animal farming and agricultural farming. Farming acres and acres and acres of corn and soybeans is destroying our top soil and promoting climate change. We got to go back to eating like our grandparents ate Lots more community farms and subsidizing community farms and not big agriculture. We've got to teach it differently in school. We've got to subsidize healthy food in school. We got to do school farms. Get those kids out growing their own vegetables, get kids cooking and learning getting in the kitchen, more family time, more family dinners.

Dr. Susan Wolver: 54:14

We are running on empty. Where are we getting all our foods Half of my patients, when they come in? Well, they have kids in high school and they're doing this ball team and this club and everything and where they're eating in the car, driving through McDonald's and there's no sitting down at the table. There's no getting your kids learning how to cook and what's healthy, how to read labels.

Brian Campbell: 54:37

Well, you got to work it from both ends.

Brian Campbell: 54:40

Well, remember that quote I said earlier my former boss, the medical school dean you have relationships with your patients. Not only do that, but you remind me a bit of an evangelist. I grew up in Virginia going to Baptist Church and it's hard to not be around you and not be excited. I feel like that's. The other thing that I think you've added to this conversation is this idea of enthusiastically wanting to help your patients get better, and I think that certainly resonates with me, and I imagine it would resonate with our listeners, who either have struggles like this or they certainly know people who have struggles like this.

Brian Campbell: 55:15

I think that's the other thing that I would do is I would clone you. I would try to figure out a way to get more people like you practicing not just in big city areas like Richmond. But how do we get more people like you? How do you access that in rural areas? Is that another? We'll wrap up with that question, and that is access to care. So how do we address this obesity question knowing that there isn't equitable access to care?

Dr. Susan Wolver: 55:38

There's a wonderful organization called the Obesity Medical Association and anybody can actually go to that site and type in their zip code and find obesity medicine specialists in their area.

Dr. Susan Wolver: 55:51

So you might be surprised that there are actually a lot more than you might think.

Dr. Susan Wolver: 55:57

So one of the goals this year of the Obesity Medicine Association is actually to work more with primary care doctors, getting them more comfortable treating obesity. I gotta say, when you start doing obesity medicine in your practice, you get a lot of joy back in medicine really seeing your patients improve and the satisfaction is just immeasurable. I'm not sure if you're familiar with something called Project Echo, I'm not. So that's a wonderful nationwide program where you take specialists at like a major academic medical teaching center and you meet with providers, physicians in the community and teach them about something that they may not be so comfortable with, and then you meet on regular basis to discuss difficult cases. So addiction is one of the things that, or substance use disorder, that we are doing a lot of, project Echo at VCU with teaching community providers and physicians how to do this in their own practices. So that's one way to kind of deliver across the Commonwealth and across the country. The Obesity Medicine Association has a two day course for people who want to learn more about obesity medicine.

Dr. Susan Wolver: 57:22

Anybody could ever contact me and I will direct them whether they are a physician, a provider, a patient how they can get access to care. So I think it's going to be more incorporated within primary care and then they're going to be more freestanding type programs, both within medical institutions as well. As you know, there are freestanding, like many weight loss and things like that. Of course, many of those don't take insurance and that's a whole other question. We didn't talk about Getting treatment for obesity for the most part has been a cash pay kind of thing. So I do something very unique where I'm doing it in an academic medical center, it doesn't cost any more to see me or my colleagues than it does for primary care copay.

Brian Campbell: 58:08

Gotcha. Well, you know it's funny and I was telling people about you been on the show. I was shocked at just how people were really interested in hearing about this, and I think that part of the other thing that you're providing in our community in Virginia is you are an advocate for this and you're clearly enthusiastic about it. You're clearly knowledgeable and you're clearly committed. So is there anything else you'd like to add before we wrap up?

Dr. Susan Wolver: 58:30

One last thing, and we touched on the beginning. I wrote it down, but we talked about, you know, what treating people and helping them with their weight can achieve. And I started to say, when patients fill out a questionnaire before they see me each time, they usually see us every sort of four to six weeks and one of the questions is what non-scale victories have you had? And again, patients come to us wanting to lose weight on the scale and we hope that they'll reframe that into leading a healthier and more satisfying life, and so I love the things that people write on their, their non-scale victories, and I'll just share a few of them with you, because I think that you know really gives hope.

Dr. Susan Wolver: 59:13

You know, in in addition to, of course, coming off of expensive medications like insulin and other expensive medications for diabetes and high blood pressure. So I have one patient who has saved $2,000 a month by not having to buy all their insulin products. We have things like I get to go on the airline and not ask for a seatbelt extender. Do you know how off-putting that is to have an embarrassing to have to ask for a seatbelt extender. And what's interesting is you know, I told you the population obesity has been skyrocketing over the past 40 years. We've never changed how long those seatbelts are. I mean they have. It seem like a pretty easy thing to do when we're making more planes. You know, people can tie their shoes. Another one that people write all the time is they can go on roller coasters with their kids. So being able to give that back to people is what makes me get up in the morning.

Brian Campbell: 1:00:10

Well, geez, you know I like to watch the Waltons, and there's always, you know, that people were betrayed. You remind me of someone from a different time and place, someone who's clearly enthusiastic not just about the work, but the difference you're making, allows your patients. So we thank you not just for being on the podcast, but thank you for everything you're doing every day for your patients and for a virginian for our country. So thank you, dr Wolver.

Dr. Susan Wolver: 1:00:32

Thank you for having me, it was my pleasure.

Brian Campbell: 1:00:34

Great. That concludes our show today. Thank you for joining Virginians of Interest podcast. We'd like to thank our host, blue Ridge PBS, for having us today. If you like what you hear, be sure to subscribe and like our podcast.

Announcer: 1:00:45

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