University of Washington medical researcher Ellen Schur studies what and how we eat, our appetites. She is a primary care internal medicine physician who recently lectured at Gonzaga University about weight management and anti-obesity drugs. She stopped by the SPR News studio to talk with Doug Nadvornick.
This interview has been lightly edited for length and clarity.
DN: Tell me a little bit about weight loss drugs. How do they work?
Ellen Schur: The newest medications that are receiving a lot of attention act on a body's natural hormone system that is designed to kind of give information to the brain about the nutrition coming in from through the gut. We have hormones that are released from our guts when we eat and they go into the bloodstream. They circulate throughout the body and they also go to the brain and that is part of what underlies our feeling of not only feeling more full, but also that feeling that we experience that the food becomes less appealing. So if you think about what it means to be full or to be satiated, it's that feeling that food doesn't look that good anymore and you kind of want to push the plate away. Part of that are these signals from the gut and so this signaling system is based on hormones. But what it's regulating are things like our perceptions of food. How rewarding is the food? How motivated are we to eat? How appealing is it? How much attention are we spending on the food in our environment? Those are the tools that our brain has to get us to obtain and consume the nutrition we need to survive.
These medications, the newer medications, work on a particular hormone released in the gut called GLP-1 or glucagon-like peptide one. And specifically, they're acting on the receptor for that hormone that is part of our natural signaling system about fullness and satiety.
DN: So how similar or dissimilar is this to, say, hypnosis? I've heard radio commercials from people saying, I go to this weight loss center and they put me under and all of my cravings go away. Are they working on the same sort of idea, same concept?
ES: Yeah, eating and appetite is very complex. There are multiple aspects to it.
There are multiple neurotransmitters in the brain involved and these medications act on one part of the system. It turns out that it's very potent. We access this system through our rational mind when we're trying to control eating. We can access hunger through emotions that might stimulate different parts of the system.
But I think what people underestimate is the potency of actually the biology driving eating and just how well tuned our system is to getting us nutrition and driving us to eat over time.
The other thing that people underestimate is how well tuned this system is to the types of food that are in our environment. We're really sort of selectively attuned to these high calorie foods in our environment.
So while hypnosis might be very effective for some people, it's hard to know which of these pathways it's really acting through. If it works for folks, great. And, you know, I'm pleased to have people access this whatever way they can that helps them.
DN: Is there a superior or preferred way to lose weight? And what you're saying is if it works for you, go for it?
ES: Well, I think it depends on what the person is really looking for.
I think folks who are looking to manage their weight over time deserve individualized and personalized care. It's not a one size fits all situation.
For me, when a patient comes in with obesity, we're going to talk about all aspects of their eating. Are there places where they're experiencing cravings? Are there places where they're just not feeling full when they eat? Are there particular situations where it becomes tougher to manage their eating? And then we're going to balance that against their health concerns.
I'm a physician. I'm there to manage a person's health. And there are many weight related comorbidities that put people's health at risk. Some of them are modest and some of them are quite serious, like cardiovascular disease and like cancer. So I'm there to help a person manage their health and we do know that weight loss can benefit many of these health conditions.
But what we've seen over time, what research shows and what a lot of folks' individual lived experience tells them is that frequently maintaining that weight loss is very challenging. What that means to me as a physician is that I'm going to be there to help the person set their goals, but also to help them figure out how to sustain that weight loss over time if they're choosing to use weight loss to manage their health sufficient for them to gain the health benefits from it and that's where these newer tools come in and are very useful.
DN: These drugs are now on the market, so they've been tested for safety. Are you satisfied that these are long term tools that we'll be able to use generations from now?
ES: Yeah. There's a couple of reasons why I'm optimistic about that.
One is that the medications that have been developed, they have been around for longer than we've been hearing about them. The first versions of these came out 15, 20 years ago and were being used for diabetes and so there are people who have been taking these for many years and we're not seeing a signal that there are long term complications.
The other reason I'm optimistic is because the signal that we're seeing actually points towards long term benefits. So for folks with overweight and obesity who are at high risk of cardiovascular disease, the most remarkable thing is that these medicines are now approved to lower the risk of serious cardiovascular events for those folks. We haven't had any tools that have done that before. So for me, seeing examples like the fact that folks with diabetes and chronic kidney disease have less progression of their kidney disease on these medications, I'm leaning towards seeing some of those long term health benefits. There are definitely side effects and there are definitely some serious side effects that arise and we have to balance that. But based on the data that's out there now, and we're getting data now in 80,000 to 100,000 people, we're actually seeing that it leans more towards benefits.
DN: So in the big picture, could it be considered to be more or less a treatment for America's obesity in general?
ES: Yeah. Interestingly, I personally think about obesity as a chronic health condition, the way we think about diabetes or high blood pressure. Many medical organizations have come forth and also agree with that. That's really based on this 30 years of science understanding this system, because what it tells us is that the body defends the elevated body fat in obesity and it does so voraciously as if it's starving. And so, really, what we're addressing is that the body's defense of elevated body fat mass prevents people from managing their health concerns when all that we offer them are lifestyle changes for long term management. It's not that those aren't important. They're a very important part of working together with these medicines and they're a very important part of people improving their health. It's just very hard to lose and maintain particularly large amounts of weight using that strategy alone. I'm happy that we have new tools to aid people in managing their health in that way and I think that they are very significant and effective tools when used safely with the appropriate evidence-based care in the medical system.
DN: Are you saying that some of these drugs are going to be long-term drugs that people may take for quite a long time rather than somebody who's looking to lose a lot of weight fast and then would drop the drug afterward?
ES: Yes. All of the FDA-approved anti-obesity medicines are approved for long-term use and that's actually the recommended use because they're not just for weight loss. They're also for assisting with maintaining that weight over time and I think of them the way I think of our other medicines for conditions like diabetes or high blood pressure.
You don't take people off their medicines once their blood pressure comes down and you certainly don't ask them to use willpower to keep their blood pressure down after they stop their medicines. So I don't think we should be doing that with medicines for weight either, given the science that we know about this condition.
