160 | Inside an Obesity Clinic: GLP-1 Dosing, Plateaus, and Prior Auths

Today's episode is not your typical GLP1 and weight loss conversation. We're not spending the whole episode talking about protein goals, constipation tips, nausea, or the average amount of weight patients can expect to lose. Don't get me wrong, these things are very important, but I wanted this conversation to be different. Welcome back to the Exam Room Nutrition Podcast. I'm your host, Colleen Sloan. I'm a PA and registered dietitian, and today I'm talking with someone who is truly on the front lines of obesity medicine. And I just love all the work that he does. So let me introduce you to Joseph Zucki. Many of you may know him by his incredible visuals that keep us up to date on the ever-changing landscape of obesity medicine. For those of you who don't know him, he is the clinical supervisor and physician associate at the Transition Medical Weight Loss Center in Salem, New Hampshire, where he leads a multidisciplinary obesity medicine program. Now his clinic has been named the best weight loss clinic center in New Hampshire three years in a row. At the end of this episode, you'll hear exactly why they won this award because they have some incredibly creative ways to help their patients. So yeah, Joe knows his stuff, and I'm so excited that he's on the podcast. So in this episode, we talk about how he decides when to increase a GLP1 dose, when to hold steady, and when it might be time to switch medications. We also talk about what he does when patients plateau, how he handles insurance coverage being dropped, and why prior authorizations are basically their own full-time job, and how he documents to get meds approved. Now we also get into conversations that patients are bringing into the exam room, questions they're asking us, things like ozempic face, muscle loss, compounded medications, and the stigma of needing a medication to lose weight and how he addresses all of these concerns. So get comfy or drive safe and enjoy my conversation with Joe. Joe, thank you so much for carving out some time today to talk with me. I'm really excited to pick your brain. Welcome to the podcast.

Thanks so much for having me. Excited to be here. Looking forward to this.

Oh, yeah, you are like the guru of GLP1s and obesity medicine right now on all the social media platforms. I love seeing the content you put out. And so I'm really excited for you to share your information with my listeners. And so one of the first things I want to talk about is social media. I think you and I both have a love-hate relationship with it. We both use it to get our content out there, but there's also a lot of misinformation. And especially around obesity and GLP1 medications. They can either be miraculous, you know, I lost 100 pounds overnight, or dangerous, and patients are coming in really scared. So I love to hear what you are hearing in clinic? What types of concerns do you address from patients who are interested but maybe a little cautious about starting on these medications?

Yeah, it's a great question. I think, you know, like you said, it's good and bad, but social media definitely has now patients are much more informed, which is great because they come in with good questions, they're thinking things through, they're kind of researching these topics. So it's a great discussion, but it also leads to a lot of sensationalized headlines and fear-mongering, and patients come in and uh kind of hear these horror stories that sometimes get, you know, broadcasted that aren't necessarily realistic. So I always try to be, you know, of course, compassionate care with patients, but also evidence-based. We can give them the facts and go by trials and data versus just anecdotes. And so I think there's a lot of different things, and we can go through one by one and kind of work through them. But some of the biggest things that people sometimes hear about is uh certainly with GLP1s, there's concerted muscle loss. And again, valid concern. We have that concern with any weight loss endeavor, whether it's lifestyle, whether it's medication, or whether it's gratitude surgery. And certainly if patients are losing weight rapidly and not eating healthy or not exercising, then yes, there's a chance of muscle loss. But that could happen with or without medication. And the medications, um, if you look at the trials, they actually have done DEXA skins and body comp analysis before and after the weight loss trials. And they saw the majority of the weight loss came off as fat mass. About three-quarters in most trials was fat mass, and about a quarter was lean mass. And that's honestly quite normal when you look at even just lifestyle weight loss endeavors alone. And so it's reassuring. But at the same time, um, I will keep in mind that lean mass is not just muscle, it also includes water weight, muscle glycogen, organ weight, and so forth. So definitely it will vary from person to person. And I always promote strength training and exercise and protein intake to mitigate muscle loss. But I think that's something that we can work through together and hopefully calms the fears that this is going to suck away muscle tissue or anything like that. Um, other things that people sometimes hear about are risks of thyroid cancer, because it's a black box warning. And, you know, that's specifically on the label of all GLP1s, dating back to the first one in 2005. But that's because rodent trials, and only rodent trials, did see a kind of dose-dependent potential increased risk of these medullary thyroid cancer. But rodents have a different thyroid anatomy than humans do. Human trials have not shown an increased risk there, or there hasn't been a signal of concern, and human thyroids do not express GLP1 receptors very much at all compared to uh rodents. And so I wouldn't prescribe it for a rat, but I think that it's safe for patients that are, you know, again, interested as long as they don't have a personal or family history of medullary thyroid cancer or multiple endocrine neoplasia syndrome type 2. Those are the only contraindications. Any other thyroid issues do not apply, hypothyroidism, even papillary thyroid cancer. So hopefully that helps people to be mindful. And honestly, if you keep in mind, these medications, again, everything's a pros and cons, but these medications may actually reduce cancer risk because it's helping patients people lose weight. Obesity is one of the highest risk factors of cancer. It is tied to over 200 comorbidities. So when we treat a patient with obesity, we are treating upstream and preventing so many downstream issues. So we're truly treating the root cause, and cancer is a reduction in many cases as well. Um, other things that I've heard, certainly things like osempic face, these medications don't affect facial fat tissue any different than anything else. They help us eat less, reduce appetite, reduce hunger, cravings, benefit blood sugar. Certainly, again, if somebody loses weight rapidly in an unhealthy manner, they could look a bit gaunt and unhealthy. Um we again promote proper, sustainable, uh, slow and steady weight loss, and that's going to lead to the best outcomes. If somebody loses a substantial amount of weight, again, no matter how they do it, there could be some loose skin in things, but these medications are not causing it inherently by themselves. Um, and I think a lot of people have concerns about GI issues, which is valid because that is the most common side effect with GLP1s. But in many cases, they are mild to moderate symptoms that often dissipate over time as patients get more acclimated to it. And we help them through that. We can adjust titration of dosage, we can be more slow with ramping up, we can also help with lifestyle changes through nutrition and again portion control and fattier foods can cause more nausea. So we try to reduce that. And so for many patients, the GI symptoms are generally transient or at least lessening over time. So hopefully that's reassuring. And I think the last piece that I have a lot of patients have fear of is this like, unfortunately, there's a lot of stigma and bias around obesity. And that's a topic that, you know, deserves a lot of debate because patients should not be criticized for being proactive about their health, right? These medications are a tool. And if somebody has high blood pressure and goes on a blood pressure medication, do we chastise them for using a tool? No. If somebody has depression, would we say, how dare you go on that medication? You got to try harder to be happy? That'd be rude, right? That'd be just inhumane. So when a patient chooses to use a medication to help with their weight, it's a tool. It's not a cop-out, it's not a crutch. Obesity is unfortunately a chronic, relapsing, progressive, multifactorial disease. And for many patients, lifestyle alone is not gonna be enough. We have to understand our biology fights us. When we try to lose weight, it sees that as a survival threat. And the compensatory response is an increase in hunger, an increase in cravings, a decrease in fullness, and a slowing of metabolism. That's why for many patients, weight loss is often followed by rate we gain, regain. And so again, the medications are not magic. They're a tool, but they certainly are a powerful tool and can help patients. So we should never, you know, chastise someone for uh opting for a tool that can help them in their health journey.

I'm so glad you went there with the stigma part because I hear a lot of friends and even colleagues that are like, oh yeah, you know, I'm like, you look great. And I'm like, oh, I lost 15 pounds, but you know, I'm on a GLP one. And they kind of like whisper it to me, and I'm like, it's okay, you know. Exactly. I'm not judging you, like, that's great. I would congratulate you the same way for your success, whether you were use this tool or another tool. So I think that's an interesting thing that I doesn't always get addressed, and but patients are feeling it, they're experiencing it. And that leads me into my next question. And I actually got this when I spoke at the Today's Dietician Nutrition Conference recently. And it was, what do you say to the person who comes in wanting the pill or the shot? You know, they sometimes call it that only. And they are pretty much very disinterested in hearing about lifestyle or nutrition, you know, exercise because they've maybe tried that. How do you approach that conversation around lifestyle change without overwhelming them or frustrating them while also still meeting them with, you know, the treatment that they're hoping to get?

Yeah, it's a great point. It really should always be done in combination with the lifestyle. It's not one or the other, right? Um certainly we need to be, you know, help patients understand this is a tool and the toolkit alongside everything else. If you look at the obesity medicine association's four pillars, that's what we try to follow. It's nutrition, it's it's exercise, it's behavior and lifestyle modification, and it's potential medication. And so it's it's it's a full picture here. These medications enable the lifestyle to sometimes be easier because we're not battling our biology of having hunger and cravings and constantly thinking about food and feeling hungry. So that's where it helps. But the medications do not, you know, reduce body fat inherently. We still need to be putting forth the proper efforts, and certainly um we want to make sure they're getting the right nutrition. So some patients um think that the goal is to just starve themselves. And that's not the goal at all here. We still want to fuel your body, get enough nourishment, nutrients, fiber, fruits, vegetables, vitamins, minerals, all these things are going to lead to the best health outcomes, the best tolerability. And of course, this focus is not about weight loss. These medications are not for vanity. If someone comes in here with a BMI of 22 and wants to use this, that is not the appropriate fit. I have to be judicious when using medications. This is designed for patients that are struggling with their weight, and we want to help them when to get into a healthy range. And so, again, for those that are looking to lose 10 pounds and do, you know, maybe uh have a normal weight to begin with, this is not the right fit. This is designed for patients that have the disease of obesity and are truly battling that. So it is a powerful tool. I don't want to make people feel like it's it can feel like magic sometimes, but it is indeed certainly still a tool. And the lifestyle is huge. And again, the exercise is important too. But like you said in the beginning, I never want people to feel overwhelmed. You know, nutrition is a complex topic, and we don't want people to feel like they're gonna leave here with a thousand thoughts. So we start small, we'll build things over time, and hopefully with the accountability and support and the, you know, guidance, we can make these habits and make this into a lifestyle. But it takes time to build those habits.

Yeah. We're gonna get into like a peek into what you do in clinic with your patients and some of the cool technology that you incorporate as well a little bit later on in the episode. But I'm really curious, and this actually came from one of my followers on Instagram, which reminds me if you don't follow me on Instagram, be sure to follow me at exam room nutrition. You can always send me questions that you want me to cover on the podcast. And someone asked if you screen for eating disorders prior to prescribing. So I'm just curious how you handle that.

Yeah, it's it's an important topic for sure. And it kind of talks about what you mentioned. You know, if a person comes in here and certainly is at a low weight to begin with, then again, we're gonna not be using these medications. We're gonna certainly help them through lifestyle changes and make sure they're properly getting the right nutrition. Um, but we want to make sure we're not using this just for the wrong circumstances. If somebody reports a previous history of a bad relationship with food, or or perhaps again, these medications may be helpful for binge eating, so there's you know, potential there. But if someone has a history of anorexia or has gone through long periods of kind of starvation diets, we want to help to encourage them that food is not bad. We want to nourish our bodies. These medications may not be the perfect fit for them. We want to make sure we're not creating unhealthy eating habits. So it is important that this is not a one-size-fits-all. We want to be screening for any of those types of things. So it's a very nuanced topic, and we want to be compassionate with our patients because they certainly come in here feeling frustrated. They've tried a thousand diets before, and we want to always be welcome to helping them. But at the same time, it's not this medication or these medications are not for everyone. And if somebody has a not a healthy relationship with food, let's work on that first, and then hopefully we can save this further down the road if we need it. So I agree it's very important that we are screening for eating disorders and thinking of this, you know, properly so we're not causing a worsening and uh relationship with food.

Yeah, I agree. I think the science is kind of yet to catch up, or maybe we just don't have the literature quite yet on GLP one's impact and eating disorders. I think it'll be interesting in maybe five years, we might have more guidelines regarding screening. Because in school, you know, we are taught like a patient with eating disorders, like the ex-gymnist who's emaciated looking, right? That was like the picture we were all taught. But eating disorders come in all shapes and sizes. And I think that disordered eating patterns can be missed for quite a while, especially to have that desire for thinness. So I think we do have to be really, really careful. Now, do you have any specific questions or maybe red flags that you're looking for that you ask, or maybe on your intake form that might kind of make your antennas go up and cause you to pause for a moment?

Sure, yeah. I think, you know, certainly I'm kind of assessing them what their current statistics are. So when patients come in here, we do body composition analysis. So we can assess muscle versus fat versus water. Again, you know, BMI, body fat percentages, weight height, all that stuff. So we can get an idea of where they're at. But also I always ask them kind of to get a trajectory of how their weight has changed over the years. Have they had, you know, periods of extreme dieting? How have they, if it's been a slow climb? Has it been ups and downs, yo-yo dieting, and how have they previously attempted to lose weight? Was it, you know, rational, healthy programs, or was it a bit more extreme options? And then it's also kind of getting a feel for their goals. If they tell me that their goal is an unrealistic weight, we want to kind of talk about that and talk about what is a healthy weight for you. And it may not be a number on the scale. I know numbers are big, but maybe it's more about I want to just get healthy. I want my lab work to be better. I want to focus on being, you know, around for my family longer. And so those are good goals to hear. If somebody says I need to be 123 pounds, then that's a little bit of a red flag, but you know, is that realistic? Because that's the weight they reported that they were in high school. You know, so we have to look full picture here and make sure we're treating the patient's health at the end of the day and not just treating for a number.

Yeah. Yeah, this is such a cool topic. And we can absolutely all learn from each other. And I, if you want to learn more about this, I interviewed an eating disorder dietitian on the podcast and she shared her, you know, her viewpoint kind of from her lens and her experience on if GLP1s could be masking an undiagnosed eating disorder. And that's actually episode 151. So I will link down to that below in the show notes. But if you want to dig deeper into this topic and learn a few questions, I think she shared like three questions that you can ask to screen before prescribing. So go check out that episode after this one with Joe. All right, Joe. So let's talk a little bit about dosing because uh I get a lot of questions about this and sometimes it's a little unclear on um escalating the dose. So I'm curious, how do you decide when a patient should be escalated and or if they should stay at their current dose? How do you make that decision?

Yeah, it's a great question, you know, and the these medications have many different dosages, you know. So we look at uh Zeppound, Foundale, they have six dosages. We GOVI had five, now it has six, uh, the pill has four. So there's a lot of different nuance there. And that's where this is again not a one size fits all. It's nice, in our opinion, to have uh more dosages because we can individualize it for each person. But again, I'm privileged to be able to see patients very frequently in my setting of working in obesity medicine, whereas patients who are getting these through their primary care providers may not have that benefit, and they're seeing them once every six months, and they may not be getting the right titration. So there's again a lot of differences there. But um, my usual kind of thought process is first seeing how someone's doing. If they're having any side effects, there's a reason we won't want to, we would not want to increase. So that's kind of one of the top things. If we're having GI issues, let's stay at this dose, allow your body to get more acclimated to it, and those symptoms should hopefully subside as you acclimate more to the given dose. Assuming they're tolerating it well, then it comes down to how are you feeling? Do you feel like your appetite's in a good place? Do you feel like your portions are controlled? Do you feel like hunger is, you know, balanced? Again, our goal is not to suppress appetite to the ground here, but we want to help us feel fuller faster when we do eat and hopefully can, you know, seeing some progress happening on the scale. If that's weight loss, great. If it's body fat reduction, great. If clothes are fitting differently, if lab work is getting better, those are signs that you know what we're doing is working. But on the other hand, if somebody is, again, tolerating it well, but they are feeling, you know, like they're plateauing, their hunger is kind of ramping up a little bit, their cravings are getting stronger. Perhaps they've been on this dose for a little while now, then I think increasing certainly makes sense. The trials definitely show that the higher dosages correlate to more weight loss at the end of the day over the course of time, but it should be a gradual rise. I'd almost I kind of want to maximize each dose as much as we can before just going up for the sake of going up. There are some patients I have that are on the second dose and doing fantastic and down more than 50 pounds. And there's others that needed to get to the higher dosages to really feel a benefit. So don't compare yourself to others. Some patients may need a higher dose, some may need a lower dose, and that can constantly change. And even when they get to their goal weight, we sometimes go down or to a maintenance dose. And so it comes down to tolerability, efficacy, and just feeling out how they're feeling like it's working.

Yeah, I think that's really helpful. Now I want to pause here and just sort of shift gears a teeny bit and talk about compounded medications. Because a lot of patients don't have coverage or they lose coverage for the FDA-approved medications and then they're going compounding. We won't spend a lot of time because this is probably an entire episode we could do to talk about compounded medications. But if you have a patient that is coming in to see you and they've been on a compounded, let's say zip bound or take any of them at a certain dose, will you start them on the FDA-approved lowest dose or will you start them on whatever dose they came in with when they were on that compounded medication?

Yeah, great question. So it's certainly, you know, personally, I always prescribe just the FDA-approved medications. And I always, of course, I try to be compassionate with patients. If they come in on a compound, I will inform them of the risk, but I also understand that they're trying to be proactive. I completely understand, unfortunately, cost and coverage can be a barrier for many patients. And so it's never about shaming them for using these medications, but it's about educating them as to why it's concerning. We don't know what they're getting, right? So that's the problem with compounds, right? These medications are branded medications, they are patented medications. Semaglatide was created by Nobor Nordisk, trzeptide was created by Eli Lilly, and those are, you know, under brand names of Wigovi and Ozepic for Symaglitide, and Zeppon and Monjaro for trzepatide. During times of shortages, which we had a few years ago, there was kind of a loophole that allowed these compounding facilities to manufacture the medication to help during the supply shortages. But there are no shortages anymore. All the medications are well in stock. And this has fortunately become the Wild West now because now it's become not about helping patients during shortage, but now it's just about marketing this towards anybody you can through social media ads and so forth. And so the compounding has blown up. And again, there may be some places that are better made than others, but they are the API, the active pharmaceutical ingredient, is a patented thing that only Novo and Lily are creating for their medications. So any compound that somebody's getting was not made by those companies. And so you just don't know where it is. Likely could have been made in China, could have made made in someone's bathtub for all we know. We just don't know. And they combine it with other ingredients sometimes to try to get around loopholes. They mix it with B12. Lily just did a study where they found that trzeptide mixed with B12 could create an impurity when put in a compound together. We just don't know. Again, it's about safety at the end of the day. We don't want to just risk our health. These are injections we're putting into our body. And the real medications went through a lot of clinical trials and vetted for safety and efficacy. And even the manufacturing process has such a stringent criteria to make sure that what you get is what was studied. And when people get a compound, there's just a lot of unknowns there. And so the FDA is starting to step in now and kind of put out, send out warnings to a lot of compounding facilities that they should not be manufacturing this anymore. So that's my thoughts. But again, if somebody is on a compound, I'm here to help them. Certainly, if they decide to switch to the FDA-approved medication, if they feel like they're on a higher dose, sometimes they don't even know what dose they're on because the compounds are kind of tricky to figure out. They're saying, I'm taking 50 units. Well, 50 units of what? So we find try to figure out where they're at. But when in doubt, I would say it's best to be conservative, start a little bit lower on the real medication, and then titrate up from there. And I always want to help them get it for the best price possible. So we'll help them see if there's any way to get it through their insurance. Some of them had coverage all along, they just didn't know it. And it was a $25 copay. But for the many, unfortunately, that don't have coverage, we will figure out what is the most effective cost option, be it the pills or the injectables, through either the manufacturer savings cards at the pharmacy or the male odor pharmacies through LibbyDirect or Novo Care. So we can help through all that. So I hope patients can, you know, find the right medication, the right dosage, and um and talk to their provider to figure out the right plan for them.

Yeah. And you do have some tips for uh documentation and how we can hopefully get these medications approved or help with prior offs, which I will ask you in a little bit. But I want to talk a little bit about the patient who has plateaued. So maybe we've got them on a, you know, normal dose, right, you know, max dose medication, they've plateaued. We've got so many different pillars to pull when we're helping them in this journey. How do you determine kind of where the issue is? You know, it could be medication. Is it more their behavior? Is it their nutrition? Is it their expectation? So throughout your conversations, how do you determine kind of what the next step is?

Yeah, it's so important. You know, and again, this is where having a comprehensive approach is important. And, you know, ideally the patient is getting that care in terms of exercise guidance, nutrition guidance, along with the medication guidance. Um, but there's so many things we think about. Certainly, what dose are they on? Is there room for increasing if they are feeling like their hunger is kind of the problem here? But it is very much looking at a nutrition balanced, you know, kind of a dietary overview. Um, if they're able to, our um kind of portal allows patients to track their nutrition. And so if they're comfortable with that concept, we can look over their nutrition log, see calories, carbs, protein, fat, and you know, distribution, and hopefully give them some feedback there. Um, you know, calorie counting can work well for some people, but I don't want to make people feel like they have to go that method because that can sometimes be tedious and overwhelming for others and create a negative relationship with food. So it's looking at your person where they're at. Um, but it is are you getting adequate protein? Because protein is very satiating. It creates more fullness. Sometimes patients are still having hunger, but maybe they're just not fueling their body with enough protein. Are they getting enough fiber? And so we're looking at, you know, fruits, vegetables, um, those things would be helpful. How's their water intake? How's their sleep? How much alcohol are they having? How's their stress levels lately? Certainly, some patients even can be on other medications that can be weight gain promoting. They were just put on a dose of prednisone. You know, these things all are things that we're thinking about that could be impacting someone's weight that go beyond just let's increase the dose. And so it should be full picture, uh, encouraging patients to, you know, certainly increase their physical activity and again in a compassionate way. Can we just increase your step count? Can we do things at home? If you feel comfortable with a gym, great, happy to help myself and our nurse practitioner here are also certified as trainers so we can make workout plans for patients. So we truly try to meet them where they're at and give them tools, but in a in a realistic way, we understand that whatever we're doing to lose weight, we want to make it into a lifestyle. And so if it's one or two workouts a week, awesome. If it's more than that, great. But I don't want people to feel overwhelmed either. So we try to start small. And so I think those are things that we're thinking about. But you know, again, if appetite is truly starting to climb and cravings are getting stronger, then increasing the dose is a perfectly valid option. Um, but we don't want to overlook those other things that could be missing links in the process.

So I'd love to hear about some of the challenges patients face after they have lost weight. Maybe they are at their goal weight. Like what happens next? What are they seeing you for? How are you now counseling them and supporting them in their continued journey?

Yeah, it's so important. You know, weight loss is one part of the journey, but weight maintenance is a whole different part of that. And for so many patients, they have lost tons of weight in the past, right? They have some patients have lost hundreds of pounds over the past, but they've gained it back. And so losing weight is part of it. But really, the goal for us is that sustainability piece. So maintenance is huge. Again, we're blessed to be able to see patients frequently. And even when they're at their goal weight, we still try to check in with them at least once a month, if possible, just to keep tabs on them. And maybe it's once every few months if we need to, but it's the accountability and helping people. So if we're starting to see a climb, we can help them right away versus letting it climb further and then have to start over from square one. And so I'd say a lot of patients, they do have that fear of regain. I will say if you look at the medication trials, there are some trials now over three plus years long. And if they stay on, you know, some dose of the medication, they are likely going to help maintain their weight long term. Um, if they, you know, discontinue the medication or come off of it because of coverage changes and things like that, there's certainly going to be a tendency of weight regain. I won't say that's going to be everyone, but there's a majority that unfortunately are biology strong and they're going to return to their previous habits because appetite will be back at its baseline. And so for many patients, staying on medication is going to help sustain weight loss, but it may not be the same dose. We sometimes use a lower dose. We sometimes space out dosages. It just depends. Um, but again, we always are reinforcing the lifestyle. So whether or not they can stay on the medication, we want to help them be successful for sure.

Yeah, it's interesting. I had a conversation with a bariatric dietitian recently. It was episode 155, and we talked about getting unstuck or helping our patients who feel like they're constantly like restarting, right? And I had asked her about how do we keep our patients successful? And she had said that the patients who have maintained their weight the longest just continue doing what they've been doing, right? It's just, there's nothing magical about it. It's just keep doing what you're doing, keep following the same dietary pattern, keep exercising the same way. So even though initial weight loss feels different than maintenance phase, if you just stay consistent, I find that that really helps with maintenance as well.

Yeah, I agree. There, there's a national weight control registry that it's been going on for a long time that tracks patients and the ones that are sustaining the weight loss, like you said, they're they're keeping the things going. You know, they're, they still are mindful of their food, they're still, you know, planning ahead their meals, they're still kind of planning their day, they're still staying active. So what you do to lose weight will likely need to continue to maintain weight. We can be small adjustments and maintenance calories versus, you know, deficits. But at the end of the day, yes, we hope that what we're creating during the weight loss phase is a lifestyle that is sustainable even when we get to the global weight as well.

Okay, let's get into a little bit of the business side of medicine, I would say. And I would love to hear how do you handle insurance discontinuation if a patient is already or has been on a medication and now they lose coverage. What do you do? Do you switch medications? I know you advocate strongly for them. So I would love to kind of pick your brain on what do we do to help our patients in this situation?

Yeah. Yeah, it's it's um something that hits home hard here because in New England in New England, uh, I practice in New Hampshire and a lot of patients in New Hampshire, Massachusetts. We had relatively decent coverage for obesity medications um a year or two ago. And over the past year, it's been just unfortunately become a catastrophe and it's been crumbling at the scenes. Um, I would say if you ask me a year or two ago, I had half of my patients had coverage through their insurance, and now it's probably about 20% have coverage. So a lot of coverage cuts happen. Um, not that the medications aren't working. It's primarily, unfortunately, that the employers that are, you know, kind of working with the insurance plans found it unsustainable to afford the medications because the demand was increasing so much and the prices were quite high. And so coverage cutting has been happening. Um, certainly we always are trying to advocate for why these medications deserve to be covered and hope that coverage gets better as prices continue to come down. But we want to help patients through this for sure. So if we zoom out for a second, obesity medications unfortunately are not a standard of care for most insurance plans formulary for drugs that they cover because of the fact that Medicare actually has not covered obesity medications since part deep plans were created back in the early 2000s. They actually have some terminology in there that says no coverage for medications that cause weight loss or anorexic drugs. It unfortunately is old terminology based on at the time we didn't realize obesity was a chronic disease. We also at the time didn't have good medications. So the older medications were stimulants and had potential heart issues, and so it had a bad rep back then, which is valid. But now we have a whole new science, we have new medications, and so there's a lot of effort. There's even a bill trying to get pushed through called TROA, the Treat and Reduce Obesity Act. That's a bipartisan bill that Medicare should just cover obesity medications and obesity treatment. And hopefully that would trickle down into the commercial plans as well, because these should be covered. They certainly have a vast amount of data showing health benefits. And the fact that obesity medications are still optional is sad. Um, imagine any other chronic disease where they just, no, we're not going to cover that. Like that's that's sad. So I do hope that we continue to fight for better coverage. And I agree costs need to come down to make it feasible, but we're getting there. Um but for those that do lose coverage, keep in mind it is often employer opt-in. So you may think, oh, Anthem covers it, or our Harvard Pilgrim or Aetna or Cygna. It depends on the subtype plan. Each employer can kind of choose what they're going to cover. And obesity medications are often an optional rider. They can choose to cover it, but they'll probably have to pay more in their premiums, or they can choose to exclude it, which they'll save money on. And so, unfortunately, due to costs, a lot of employers have just dropped it from coverage. Unfortunately, no matter what we say as providers, I know patients will ask, can you appeal it? Can you try? If it's a plant exclusion, no matter what we say matters, unfortunately, it is excluded from coverage regardless. Um, but you can think of it as three buckets. You have patients that have coverage for obesity medications straight away, which is the best scenario, but it's rare. You have some patients that don't have a coverage for obesity, but the medications sometimes are covered for secondary comorbidities. So Zeppon is approved for obstructive sleep apnea. Wigovi is approved for reducing the risk of cardiovascular disease in patients with a previous history of a heart attack or stroke. And Wigovi is also approved for MASH, which is a more advanced type of fatty liver disease. And so some plants don't cover it for obesity, but they will cover it if the patients meet those criteria. A good example of that actually are Medicare Part D plants. A lot of them cover it for those indications. We'll talk later about the bridge program that's coming in July, which will be even more exciting. Um, but then the third bucket is unfortunately the plant exclusions, where they just don't cover it no matter what. And so if a patient does lose coverage or fall into that third bucket, um, then it kind of comes down to their openness to consider pinning out of pocket for the medications. Those are not feasible for a patient. Um there are also some older medications that are still sometimes useful. I know they don't get as much, you know, excitement, but things like fentramine, contrave, uh, kusimia, some of these medications are, you know, $100 a month without coverage and you know, even lower to $20 a month for some of the generic equivalents. And so there are options that are still suitable for some patients if we need help with that, you know, biology and the appetite piece. Uh, but again, we're always going to support them medication or not with the lifestyle changes. But I hope that helps paint a picture of cost coverage and kind of how that all works.

Really helpful. That was like a masterclass you just did in like five minutes. So that was awesome. How are how receptive are patients to the older agents? Because, like you said, there's not as much like, ooh, ah, you know, fanfare regarding the older ones that have been around for a very long time compared to like the GLP ones. But if that is an option for someone, if you present that, are they receptive to it or do they just want to do lifestyle?

Yeah, I think it definitely, you know, people don't come in to people asking for those medications. It's not getting the attention online. And I understand the GLP ones have a lot of, you know, excitement behind them. But I think for the right person, they may not achieve a significant as significant amount of weight loss, but they still can achieve, you know, 10, 12% weight loss and sometimes more if the right lifestyle is implemented alongside it. And so we we want to just offer all options to patients. I actually made a chart on my LinkedIn showing all the obesity medications that are currently FD approved and rank them by efficacy, but also by price so people can kind of see, you know, what's the options are. And I'll sometimes show that to patients and help them understand, you know, so we can figure out their budget, how much weight they're looking to achieve, and then also making sure the lifestyle is implemented alongside it. And so I think that they have it the play, they definitely have a place in the toolkit, and they certainly can be effective. Um, but I think a lot of patients are excited about GLP1 just because there is uh so much talk about them. And there is also certainly some benefits that only GLP ones will carry in terms of blood sugar benefits and inflammation reduction that probably go a fit beyond just appetite.

Yeah, that chart that you are referencing is absolutely fantastic. Thank you for letting me use it in my last presentation. It's incredible. And I really like that you use it with patients. It helps you make this decision with them. So what a fantastic resource. I will link down to uh his LinkedIn post that has that chart. He's graciously provided so many incredible resources for those of us in obesity medicine. So uh I'll link down to that in the show notes so you can get connected and grab that chart for sure and use that with your patients. Um, I got questions on social media about documentation. And so I would love any tips or tricks you have on what we should be including in our note to either help with coverage or if we have to do a prior auth or any kind of you know insurance conversations.

Sure, yeah. It's so important. You know, prior authorizations are a complex uh thing. I do them myself for patients, so I can understand firsthand kind of the battles there. Every insurance has its own prior authorization form, and the questions can vary. Some are three questions, some of them are 25 questions, some of them need a ton of documentation, some just take our word for it. So it really depends. I mean, the basic principle of prior authorization is these are higher expense medications. Insurances want to make sure they're being used judiciously, and they want to make sure the provider is showcasing why this person is a good candidate for it. So at the end of the day, it's it's a fine principle to have a prior authorization in place to make sure it's not being used just off-label for people who are looking for, again, for vanity weight loss. Um, but it also unfortunately just complicates the process because prior authorizations add a lot of time to our plates as providers. It often has delays in hearing back from them. Sometimes you submit everything and they still deny it for no good reason. You have to appeal it and it leads to headaches. But for most patients, the process is relatively, you know, something that we're familiar with and can get it approved when it's covered. Um, so if the person, you know, first is worth checking with their insurance, do they offer coverage for these medications for weight management? You also have to ask because some people say, oh, I have coverage for Ozempic or Monjaro. And yes, most plans do cover those, but for type 2 diabetes, those medications will need an A1C over 6.5 or a fasting glucose over 126 to qualify, among other things, sometimes. And so for those that do not meet those criteria, they will not be eligible for those medications. But the obesity medications are often based on BMI. And so we can argue about the validity of BMI as a metric of obesity, but it certainly has been around for a while, and that's what's used by most insurance plants. And so these medications are approved for typically obesity, which is a BMI over 30, or overweight with a comorbidity. Overweight is typically considered a BMI over 25, but a lot of insurances go by a BMI of 27 or higher because that's what the studies often were done on. And so those are the criteria, but insurances can make up their own rules. They can move the goalposts, which is frustrating. Sometimes I'll submit a prior off and they'll only cover it if the patient has a BMI over 35 with a comorbidity. And again, they can do whatever they want, unfortunately. But for many, if they do cover it, it's often what I just mentioned are the criteria. When your provider submits it, you want to make sure that they're submitting it appropriately. Hopefully they're filling out the form. They're documenting either with chart notes or with a letter showcasing the criteria has been met. And often not only is BMI required, but typically it asks for is the patient enrolled in a comprehensive program that includes lifestyle counseling? Have they tried previous attempts? Have they tried maybe previous medications? They're looking full picture oftentimes. And so those things would have to be documented and uploaded. Um, keep in mind also that if the prior authorization gets approved, that's usually approved for like six to eight months, and then you have to do another prior authorization, and that's a renewal prior off. They're at that point, now they're not looking for criteria to qualify. Now they're looking to criteria to maintain therapy. And so at this point, usually the insurance wants to see has the patient lost at least 5% of their body weight since starting the medication. That's the common threshold for them to consider it worthwhile to continue covering it versus it doesn't look like it's doing much for the person. And so at that point, prior the prior authorization process, it's important that the provider is documenting that this is a continuation, because even if a person's BMI is now 24 and perfectly normal, we should still be able to get this person approved because they started with a qualified criteria, you know, such as a BMI for 30, and we are now showcasing that they have lost at least 5% and proving the benefit that has been achieved. And so I a lot of patients do wonder, like, oh, once I my weight becomes normal, I'm gonna lose coverage. And that shouldn't be the case. Certainly, coverage can end because the employer opts out of covering it. But if the coverage is still there, the renewals can continue to be approved as long as you've showcased some progress on the medication. So I hope that helps. Again, patients that have Part D plans to Medicare, those are often covered for patients that have like sleep apnea or previous heart attack or stroke. So the provider would need to document proof of that. They like Zetbond, for example, it needs to show an AHI score of at least 15 to qualify as moderate sleep apnea. And so those are just things that providers have to be thinking about when doing prooperizations to make sure someone qualifies. It's a complex uh thing, but it's a, you know, after a while you just know the system.

Now, in LinkedIn, you recently talked about the future of obesity care is not just better medications, but better systems and support. Amen to that. I fully agree. And so I think your clinic and what you do is really the cutting edge of obesity medicine. So I would love to hear what you do in your clinic to support your patients and to really be that comprehensive care center.

Yeah, it's um, it's truly uh I wake up every day, enjoy what I do, and love what I do because I can help patients, but it's fun to kind of build our program into the best that it can be. And from the beginning, we've always had this goal of making truly the most comprehensive program we could. Uh, and it's fun to kind of see that mission kind of continue to be accomplished. But uh, our practice is very comprehensive. We uh have patients come in, we do body composition analysis so we can see all the metrics that I mentioned earlier. They get a meeting with one of our providers. We have several medical providers, such as myself, our nurse practitioner. We also have a registered dietitian on staff. Um, so we really try to focus on that full picture of not just the medical process, but also the education around nutrition guidance. Myself and our nurse practitioner, of course, happy to help with nutrition guidance as well. And also we create workout plans for patients because we have that personal training background. We often try to do weekly check-ins, especially initially, just to create that accountability and support. Studies have shown that the more touch points you have, the better the success will be. So I understand everyone's gonna be different depending upon things, but we try to create that accountability there. Um, in addition to that, certainly we can prescribe the medications. It's never mandatory, it's always just a provider-patient discussion and just an openness to it if they're if they have questions. Um, we uh also do support groups here in our office. We typically do monthly support groups. We have a social worker that lost 100 pounds in our program, and she's a great advocate and helps patients kind of work through the lifestyle changes as well. Um, what makes us truly unique is we actually have a full marketplace in our store. And this is something that like everyone's kind of shocked when they come in here. But we have 600 foods in our store here. We have freezers and fridges and fresh meals. We partner with two local restaurants that make about a dozen fresh meals for us that deliver weekly, and they're all portioned out. The macros are all accounted for. They're kind of healthier versions of comfort food. And so those are nice options for those that need more structured meals. We have protein shakes and bars and things like that. But we also have, again, fresh salads and yogurt and cottage cheese and try to give patients as much variety as they can for those that need some, you know, help with that and need nutrition guidance. Um, outside of that, we have a lab on site, so we can do lab work when we need to. And we do offer both in-person and virtual visits. So for those that are not in the office, we can do things with them remotely if they're in Massachusetts or in New Hampshire. And so that's been exciting to have that opportunity to build this program. Last year, we started taking insurance, so the program has certainly grown a lot because of that. And we now use an online portal that allows us to track patients' nutrition. If they want to, they can track their workouts with their smartwatch. They can message us anytime with questions. We send out a tip of the week to them, and we created this new meal plan generator on there. So there's a lot of cool features that now we have access to through the kind of the technology side of things too.

That is so cool. I heard you talk about the market on another podcast, and I'm like, that is so awesome because that's a whole nother piece. Like we often forget that the patients live outside of our exam room walls and they have to go and do all the things that you just shared with them. And it can be extremely overwhelming, especially when they're just getting started. This is brand new to them. So I love that you have meals or just healthy options that kind of eliminate that decision fatigue for them. So I think that's absolutely brilliant. And so another one of my listeners asked me if you notice a difference between success rates regarding telemedicine versus in-person experience.

Yeah, it's a great question. I'd say, you know, certainly there are some, unfortunately, telemedicine programs out there that are just pill mills giving out GLP1s and there's very little supervision, right? They basically no one's ever meeting with these patients. They're just getting a sending a message to say I'm due for refill. And there's probably some app features available, but most patients are taking advantage of it. So unfortunately, those programs may not have the best success rates. I'm sure if patients, you know, do utilize the right tools, they may have good success. But I'd say there are some programs out there that are very simplistic in that sense. But um I'd say in our practice where we actually are, you know, seeing patients and doing one-on-one visits with them, we have good success both in person and online. Uh, I would say a lot of our patients that do uh online are still coming in every so often in person, so they can get the benefits of our body composition analysis. They can get the benefits of using our marketplace if they need anything for that. Just having the accountability in person is always wonderful. Um, but I'd say we've had great good success stories, and patients have had, you know, tremendous uh transformations, even doing it purely virtually.

Joe, my final question is looking ahead, like what are you most excited about in the future of obesity medicine?

Yeah, this is such an exciting time in our field, and we're just at the forefront. We're finally starting to have just such great therapies, and it's so exciting to be in this field. I know there's some frustration about coverage and costs and all these different things that people go through, but the future is so bright. I always try to stay optimistic in general with the glass half-full approach, but I truly feel like the future is going to have better costs, better coverage, but also so many good things are coming. So, first, starting July 1st, Medicare is going to start covering obesity medications for patients that have a Part D plan or have Medicare Advantage plans. This is the first time in history that Medicare's covered obesity medications. So it's exciting. It is kind of a demonstration program. It'll run from July 1st this year until the end of 2027. And then we hope that the Part D plans will opt into this balance model and continue covering it from there. But just to summarize briefly, starting July 1st, anyone, it doesn't have to be opted in, anyone with a Medicare plan Part D or Medicare Advantage would be eligible if they meet these three criteria. A BMI over 35, uh flat out, a BMI over 30 with either heart failure with preserved ejection fraction, uncontrolled hypertension after trying at least two medications, or chronic kidney disease stage 3A or higher. And the third group, which is quite exciting, is a BMI over 27 with prediabetes, which is probably a lot of people, as well as 27 or higher with a previous history of heart attack, stroke, or symptomatic peripheral artery disease. And so those are. They're going to be the criteria. And it's not just current statistics, but also qualifies patients who are on the medication now, perhaps penny out of pocket. You can go by your stats prior to starting those medications. So prior to initiating therapy. So very exciting for us to have uh, again, better uh coverage for patients. There will be just a flat $50 copay, and this will be available for Wigovi, Wigovi pill, Zeppound in the quick pen format, and um Foundaleo. And so exciting stuff. Um I have a post on LinkedIn to kind of summarizing those criteria as well, but there will be more to come in terms of this process in the coming month, but that's super exciting. So, aside from that, there are dozens of medications in trial right now looking at obesity, type 2 diabetes, sleep apnea, and so forth. Um, but within the next three years, I mean, there's probably going to be at least, you know, five to ten new medications coming out, many of which continue to target GLP1. Um, but you will see other medications targeting multiple different things. Zeppon RE targets two, GLP1 and GIP. Um, they have a medication from Lily coming out called Ratatritide that is a triple agonist that also targets glucagon. And they just released the phase three trial showing almost 30% weight loss and even more than 30% weight loss in patients that had a higher BMI over a longer period of time. Um, there's also uh allorolintide, which is an amulet peptide from Lily that's showcasing very good data and maybe even better tolerability. Um, there are medications from uh Burring or Engelheim, such as Cerrotitai, that targets glucagon with GLP1. And glucagon can really help with liver fat reduction and may even have a metabolic benefit on calorie expenditure. Um, there's also medications coming out from uh Amgen called Maritai that may be a once-a-month injection with a GLP res uh GLP1 agonist and a GIP antagonist, which is interesting. So not just a few, Pfizer and Metcera, um uh Zealand, there's many more medications in the trials. So it'll be great to just have more tools for patients. I hope that with competition, costs come down. And in general, again, medications are not for all and they're not one size fits all, but it is nice to have um different options so we can find the right fit for our patient based on what's working for them.

Man, it's so exciting. I mean, this is the time to nerd out. Like the scientists are probably just so excited at the advancements and the rate in which these all of these new trials and things are being studied. So it's really, really cool, really fascinating. Thank you for keeping us current on all of these medications. Your content on LinkedIn is so great. I've referenced to it a bunch of times. So for those people who are interested in obesity medicine or who would like to just follow you for all of your wonderful resources, where can people connect with you and you can share your clinic as well for those who are in the uh Northeastern area?

Sure, yeah. Um, if you follow if you have a LinkedIn, you can follow me on there, just Joseph Zuki. I try to post a lot of content about new trials, new information about anything in the world of obesity medicine in general. Um I'm also on the board of the New England Obesity Society where we do podcasts or webinars and different topics, and many of those are free for providers who want more education. And it's not just medications, it's also talking about lifestyle and uh, you know, preventing side effects and different things like that. Um, and then outside of that, in my practice, if anyone lives in New Hampshire or Massachusetts and would like um to potentially work with us here, uh our website is transitionsalem.com. It's Transition Medical Weight Loss in Salem, New Hampshire.

Awesome. Thank you so much for sharing your knowledge. This has been so great. I always love learning from you and chatting from you. If you want to learn more from Joe, he also is part of the Obesity Medicine Nutrition course. He gave us a lecture on the updates of obesity medicine 2026, which you'll probably have to come back in a couple months and update that lecture again because things change so quickly. But that course you can get 10 and a half continuing education credits and learn from experts like Joe. I will link down to that below in the show notes, but you can find the course at exam room nutrition.com slash course. Joe, thank you so much for the gift of your time today.

Oh, thanks so much for having me. Such a pleasure talking with you, and thank you for all that you do to promote the education to both providers and patients. Uh so excited to be here and uh looking forward to the next one.

Thank you. And thank you guys for carving out some time for nutrition today. I hope you have a great week, and I'll see you next week.