What to Know About Obesity Medications and Uterine Cancer Recurrence

00:00:00:00 – 00:00:28:12
Unknown
Hello, everyone, and welcome to tonight’s webinar. What to Know About Obesity Medications and Uterine Cancer Recurrence. I’m Kitty Silverman. Uterine Cancer program director at Share. Before the presentation begins, I’d like to tell you a little bit about Share. Share is a national nonprofit that supports, educates and empowers anyone diagnosed with breast or gynecologic cancer and provides outreach to the general public about signs and symptoms.

00:00:28:14 – 00:00:36:06
Unknown
For more information about our upcoming webinars, support groups and helplines, please visit our website at Share Cancer Support Board.

00:00:36:06 – 00:00:44:21
Unknown
We’re very excited to have Dr. Michael Garcia joining us as today’s speaker. And now I’d like to hand it over to Dr. Garcia to introduce himself.

00:00:45:05 – 00:01:13:05
Unknown
Thank you. Ms.. Silverman. Good afternoon, everyone. Good evening. For those joining on the East Coast, I’m an East coaster myself, born and raised in Maryland. So glad to speak to everyone tonight. Thank you. Thanks, everyone, for joining us. My name is Michael Garcia. I have been practicing nutrition, medical nutrition for about six years now. I’m actually an internist trained in internal medicine with a subsequent focus in medical nutrition.

00:01:13:05 – 00:01:44:05
Unknown
So I actually kind of spans the full spectrum of nutrition from, I call it under nutrition to over nutrition and everything in between. So a part of my goal is to really help, hopefully many of you navigate this important topic, and I know there’s a lot of information out there. So part of my goal and then I hope to stimulate a lively discussion towards the end so it’ll seem a little bit lecture like, but hopefully we can have some good discussion at the end.

00:01:44:05 – 00:01:48:05
Unknown
So glad to be joining everyone. Thanks for tuning in.

00:01:48:05 – 00:01:53:11
Unknown
What to know about obesity medications and uterine cancer recurrence.

00:01:53:17 – 00:02:26:17
Unknown
So wanted to just present these points just so everyone knows what to expect from from tonight. We can definitely go into more than this. But describing MBC as a risk factor specific to uterine cancer. A little bit about the background of nutrition oncology, what that means, and then really delving into the history of current and then near future pharmacologic treatment that we have for obesity in the context of uterine cancer recurrence and why they’re important when taken both together.

00:02:26:19 – 00:02:56:10
Unknown
And then like I mentioned a little bit ago, hopefully this can help everyone navigate the information out there to some extent, depending on your specific situation. So we want to just very briefly define obesity. There’s a lot out there today about body mass index, obesity. What’s actually unique is we still use these BMI body mass index categories to define obesity.

00:02:56:12 – 00:03:19:20
Unknown
Obesity is really better defined as excess adiposity. So body mass index alone does not define it, even though it’s easy to do at any sort of visit with any of your practitioners. Everything you read, it’s based off of these categories here. So I don’t want to get too much into sort of that classification, but this is the traditional classification.

00:03:19:20 – 00:03:47:01
Unknown
You can see on the right hand side how they’re classified. We do need to take into account everyone’s individual characteristics which are important age, gender, ethnicity. If someone has any condition that may lead to swelling, different amounts of muscularity depending on ethnicity too, we know that there are certain revised cutoff marks when we can see excess fat tissue, which is excess adiposity.

00:03:47:01 – 00:04:17:18
Unknown
As you see here, anyone of South Asian, South-East Asian, East Asian descent and then anyone in the Latin or African-American population, we know that there are obesity and metabolic conditions. Things like diabetes, fatty liver, high cholesterol disproportionately affect some of these populations. We also use waist circumference as an additional measure, not the only thing we may do during a clinic visit, but again, we need to be aware of different cutoffs.

00:04:17:20 – 00:04:49:08
Unknown
These are general markers, but also sort of a complementary measurement that we can use as well to why is BMI, body mass index, uterine cancer, why are they important and why are we kind of even talking about this topic? Well, they’ve done a number of review articles where they take a collection of many, many different studies and they look at the association between body mass index and uterine cancer incidence.

00:04:49:08 – 00:05:13:02
Unknown
So any first diagnosis of uterine cancer you see at the top of the list here that that box, the gray boxes just to the right of the vertical dotted line. So we know that there’s an increased risk with elevated BMI, that middle category where it says overweight, we see an increased risk 1.55. Anything above one for that h.r.

00:05:13:03 – 00:05:37:20
Unknown
Stands for hazard ratio constitutes increased risk. And then on the right hand side, you see obesity. That’s an even higher hazard ratio. So we know that there is an association between the two. It doesn’t imply causative. Meaning if you have an elevated bmi that you will necessarily be diagnosed with uterine cancer. Again, it’s just an association that they’ve seen here.

00:05:37:20 – 00:06:06:08
Unknown
We see different types of uterine cancer as well. You can see on the left hand side, it kind of breaks down the body mass index category. And you can see with increasing body mass index, there’s increasing our stands for odds ratio kind of similar, but increase risk at each body mass index category above sort of 25, which is considered, I’ll say, quote unquote, normal because there are exceptions to that.

00:06:06:08 – 00:06:35:16
Unknown
But that’s to sort of present why it’s important, why we are talking about this topic. It’s even more important because we know that really with every year that passes specifically in this country, that body mass index incidence of overweight and obesity is just growing year by year. We know that 42% meet that criteria for obesity based on the body mass index cutoff.

00:06:35:18 – 00:07:07:05
Unknown
This was as of 2020. So that’s even increased now as of 2024, we know the medical costs are very, very high, to say the least. This includes treatment of certain malignancies, including uterine cancer. This actually applies to every race, race, ethnicity, depending how you classify things. So this is the overall incidence of obesity, but it applies to everyone across the board.

00:07:07:07 – 00:07:50:09
Unknown
Nutrition, oncology. I want to just give you a brief taste and then really kind of jump into a little bit more specific about uterine cancer. But nutrition oncology is very a very large umbrella and encompasses when we think of different nutrients, so different vitamins, different minerals, fiber protein, things like that and its relation to either protection against cancer, increased risk of developing cancer, then we kind of get into the full food sources, any full or whole fruits and vegetables, anything that comes in a package, macronutrients, that’s where the proteins that carbohydrate come into play.

00:07:50:11 – 00:08:28:09
Unknown
And then we like to think actually even more so in a little bit more effectively into what we call nutritional intake pattern. So not just are you having this individual food, but are you pairing it with other good individual foods or is your overall nutritional intake pattern not ideal, but you’re incorporating carrots every day, for example? So the intake pattern is really much more important, much more lends itself to what our bodies are exposed to on a day to day week, month, yearly sort of chronic basis.

00:08:28:09 – 00:08:56:04
Unknown
And so that’s why it’s more important. This is a very busy slide, so I apologize. But the reason I wanted to present it to you is they’ve actually done some computer generated models in terms of what constitutes a healthier intake pattern and maybe not so healthy. And these were all based off questionnaires of individuals like you and I into what they eat on a day to day basis.

00:08:56:04 – 00:09:25:01
Unknown
So you can see red and blue lines, just the squiggly lines. The red kind of encompasses what we would commonly referred to as that less healthy nutritional intake pattern. You can see a propensity towards things like potato chips, snacks, dipping sauces, certain plant oils is kind of more prevalent. Some potato is, you know, processed meat. The healthier the blue one, higher amounts of legumes.

00:09:25:01 – 00:09:57:20
Unknown
So lentils, edamame, soy products, vegetable soup, cooked vegetables, raw vegetables. And I didn’t want to present this slide because there are a lot of different cancer types that they’ve looked at and they looked at many, many different nutritional intake patterns, some of which you probably have heard of the Mediterranean pattern, your low carb healthy eating index that kind of plays into this computer generated pattern as well.

00:09:57:22 – 00:10:27:09
Unknown
But they’ve looked at associations, so not necessarily new information, but what we know which is constant or more chronic exposure to healthier foods and a healthier pattern is better for our body in terms of reducing risk of many chronic diseases or improving the status of those diseases or helping to prevent or sorry prevent recurrence. And that includes many different types of cancers.

00:10:27:11 – 00:10:58:00
Unknown
So over 50 plus years there, every so many years, every 5 to 10 years, the general consensus recommendations for cancer prevention and these are extrapolated to include during treatment and when someone sort of post treatment, these are the recommendations and they really haven’t changed to a large degree. None of them are anything brand new, but we always need to remind ourselves of these.

00:10:58:00 – 00:11:32:08
Unknown
So especially with uterine cancer, be at a healthy weight again, that’s body mass index. And I should say that comes with caveats depending on on your individual characteristics. But being physically active or getting wholegrains, vegetables, fruits, beans, limiting fast food, other processed foods that are high in fat starches, concentrated sugars, are we limiting sugar sweetened beverages and limiting red and processed meats, limiting alcohol, more and more?

00:11:32:10 – 00:12:08:10
Unknown
Yes. Well, there historically have been some benefits to alcohol consumption overall. A lot of the professionals society is really moving towards less is more, not necessarily using supplements for cancer prevention. If you are a mother and breastfeeding, if you can, after a diagnosis following all of these recommendations, being consistent with all of these recommendations with why weight loss is important, we know a number of different benefits.

00:12:08:12 – 00:12:30:06
Unknown
We see here the percentages on the right, that’s actually the percent weight loss from anyone’s starting weight. So we start to see some improvements in these conditions listed here. A lot of the improvements start at 5%. So I commonly asked, well, how much weight do I need to lose? I used to be this weight in my twenties or thirties.

00:12:30:08 – 00:12:58:23
Unknown
Now I’m 50, £60 higher than that, you know, Do I really need to get back to that previous weight or how much weight should I lose? Well, the answer is it really. We see a lot of benefit in small increment, so lot of improvement at 5%. So if you’re £200, that’s £10. It may not seem like a lot initially, but we know in some of these markers and quality of life scores, we really see a lot of benefit.

00:12:59:00 – 00:13:30:01
Unknown
And then with each percentage above 5%, 10%, we see further improvement. That includes that 15 plus percent improvement in what we call call all cause mortality depending on the underlying risk factor. So this is just a general algorithm when we approach what we call weight management. So we have a lot of people referred to us for elevated BMI.

00:13:30:03 – 00:14:02:02
Unknown
That does not necessarily imply excess fat tissue. It may we generally see a correlation. So if your body mass index is above that 25, you know that normal range, it may or may not mean you have excess fat tissue. But in general this is how we approach anyone who comes to us with elevated BMI, right? So the staple of all of this is nutrition modification, physical activity within someone’s constraints, behavior modification.

00:14:02:04 – 00:14:31:16
Unknown
And that behavior modification incorporates nutrition, physical activity, but also sleep stress. Any other really hurdles that prevent maintaining a healthy weight? The next step is pharmacotherapy, and that’s what we’re really going to jump into. But there are certain individuals that may or may not qualify for medication and therapy. In addition to that foundation of nutrition, physical activity, behavior modification.

00:14:31:18 – 00:14:57:18
Unknown
I present surgery here just because it’s part of our our algorithm and what we may consider for the right individual. But medication wise, I want to jump in and really spend the rest of the time that I’m talking focusing on that, what the options are, what the future holds in terms of medication. So these are the individuals that qualify for medication.

00:14:57:20 – 00:15:24:07
Unknown
The society still don’t take into account those ethnic differences, but we need to take that into account depending on the person in front of us. So if someone has BMI elevated above 25, those foundational steps, we do that regardless if their body mass index is over 27 with a weight related condition like diabetes, high cholesterol, high blood pressure, we can consider medication.

00:15:24:08 – 00:15:53:03
Unknown
Or if your body mass index is greater than or equal to 30 on its own, These are all of the different medications we frequently will use or consider. So left hand side is more important to pay attention to. These are the ones that are FDA approved in red. Those are the ones FDA approved for long term use. Long term meaning greater than three months phentermine at the top.

00:15:53:03 – 00:16:15:24
Unknown
Some of you may have heard of that’s technically only approved for three months of use because it’s been around for so long. They did not do particular studies evaluating it beyond three months. So that’s why it’s not approved beyond three months. But not to say it cannot necessarily be used in that way as long as closely monitored the right hand side.

00:16:16:00 – 00:16:48:05
Unknown
Again, I don’t want to flood you with a whole bunch of names, but other medications that we may use in conjunction with the left hand side or depending on other conditions you may have, these are also used and they do have some sort of weight effect. So in green, those are the ones we use in type two diabetes or elevated blood sugar In purple, they’re used and those are used for anyone with a history of seizure and or headache history, bupropion also called Wellbutrin.

00:16:48:05 – 00:17:22:05
Unknown
We use that for depression or smoking cessation. Naltrexone we use for alcohol use disorder. So not directly something we would start for the primary purpose of weight management, but they can have a weight effect. So very briefly about the timeline, I’m going to give you all the names here just because reason I’m presenting this is just to show you still how young it is in terms of the timeline for approved medications for weight loss.

00:17:22:07 – 00:17:44:05
Unknown
So for many, many years, 40 years, all we had was found to mean the oldest, very effective appetite suppressant at the bottom. Those are the ones that are now they’ve been taken off the market due to various side effects. There was a medication called FEN for women with an F was paired with Phentermine, but it had some cardiovascular side effects.

00:17:44:05 – 00:18:20:07
Unknown
So that piece is taken off the market. The phentermine is still available. But then you see in 1999, something called Orlistat, which will go through and then really in the last ten, 12 years is when majority of things have been approved and really half of those within the last three years. So Phentermine topiramate will go over all of these 2014 two medications were approved and then in 2021 Semaglutide is will go be and then just most recently found or the generic name is turns up at target.

00:18:20:09 – 00:18:50:01
Unknown
So all of these medications work in some way on appetite and satiety satiety as that feeling of fullness we get after a meal. So right after a meal our body should prevent further intake. We should feel that satiety or the satiation. Not everyone feels it to the same degree, but the left hand side, right hand side. There’s been in the remote past some testing of how do we increase metabolism.

00:18:50:01 – 00:19:16:17
Unknown
We hear that term a lot and they tried it with things that affect our biological mechanisms in very severe ways. And ultimately certain things are affected to such a degree that they can lead to death. So increasing metabolism, how we think of it classically is not something that’s safe to do. Others actually do decrease energy absorption. So we’ll go through this, but there’s no medication where we don’t absorb fat.

00:19:16:19 – 00:19:45:12
Unknown
There’s another one that’s used for diabetes that we do not absorb glucose, but most of them work on appetite satiety. All of them work in some way, at least partially centrally in our central nervous system. And there are a lot of different components of how our brain processes, processes, hunger cues and cues that make us feel full. There is what we call homeostasis.

00:19:45:12 – 00:20:17:10
Unknown
So trying to really maintain the status quo, we take in energy, we expend energy. We’ve got to maintain a balance with that, that reward center on the right that plays a huge role in everyone to a different degree. It’s not just about our desire for something and then acting on that desire. There’s a lot of biological mechanisms when we see something or smell something or if we’re tired, that reward center really starts to act in a way we don’t really have much control over.

00:20:17:12 – 00:20:38:10
Unknown
But we know that’s involved in feeling of hunger and intake and feelings of fullness and then cognition. That’s of course, part of the central nervous system as well. But the brain is releasing different chemicals to try to stay in the balance. The good and bad thing is we don’t have complete control, really not much control over the release of those signals.

00:20:38:10 – 00:21:04:12
Unknown
That just happens without our saying no. Okay. Or what we’re saying to stop that release. So these are the medications I presented on that timeline slide. I’m going to go through a few of these a little bit quicker, but Orlistat still available. It’s also available actually over the counter as well. If any of you have heard of Ally, Ally, that’s what Orlistat is.

00:21:04:12 – 00:21:41:01
Unknown
So basically it prevents our body from absorbing fat. So if we eat any anything higher in fat, our body is not going to absorb it. Likely we will have increased flatulence, maybe diarrhea, maybe fatty stool. We are at risk for not absorbing certain vitamins, but we’re basically mal absorbing calories specific to fat so it can be helpful. I wanted to present this the graph on the right hand sorry, left hand side that shows the percentage of weight change versus in red versus the gray or black lines.

00:21:41:03 – 00:22:12:08
Unknown
That’s what we call placebo. So without the medication, so close to 11% over about a year in the initial study, they did in the early 2000. But when we think of what we call relevant weight loss or at least 5% from that starting point, only about 30, 35% of individuals taking this reached that cutoff. So effective, typically what we see is the side effects preclude long term use, even though it is approved for long term use.

00:22:12:12 – 00:22:37:23
Unknown
So helpful but usually not well tolerated. Phentermine I mentioned one of the well the oldest appetite suppressant. It works in a similar way to any stimulants that any of you have heard of. It’s a what we call sympathy mimetic and so it it activates our sympathetic nervous system and it acts on certain receptors in our brain to inhibit feeding.

00:22:37:23 – 00:23:12:00
Unknown
So it’s an appetite suppressant because it’s in the stimulant class. We see anything in terms of those increase in symptoms like increased heart rate, blood pressure. It can affect sleep, cause anxiety caused us to feel restless. We see dry mouth quite a bit as well, pretty good results. And we actually see that carry into now the initial studies they did, like I mentioned, were just three months, but we saw a good amount of weight loss close to about 10% and this was just over three months.

00:23:12:00 – 00:23:37:07
Unknown
So they haven’t done studies on phentermine, similar to a lot of these other medications, which the studies are about 12 months or about a year. But good results after three months, pretty well tolerated of course, depending on your your underlying conditions, something we still use frequently today. Of course, I should mention all of these medications. There are reasons we can and cannot consider giving them.

00:23:37:07 – 00:24:00:05
Unknown
And that’s always something that should be evaluated depending on the individual that may be prescribing these for you right hand side. Various doses for the center mean just so you’re aware of. So there there’s quite a bit of variation in terms of how we can tailor that center means. Also more recently in the last ten years or so been paired with something called topiramate.

00:24:00:07 – 00:24:23:07
Unknown
Topiramate on its own, used for headache prevention. If any of you have migraines, it can also be used. If someone has a history of seizures, it’s one of the options there. But together they each actually have an effect on appetite. So when paired, they both work slightly different ways, both slightly, or are both affecting appetite in different ways.

00:24:23:09 – 00:24:47:04
Unknown
So a lot of sort of jargon here. But that point about inhibitory effect on NPY is a G group. That’s one of the areas in our brain that at least one of the areas that we think affects appetite. And so any time we eat or following eating, there is a feedback mechanism essentially that prevents us from eating more.

00:24:47:04 – 00:25:22:17
Unknown
So many of the mechanisms decrease intake and work to prevent further intake of energy calories. This does this to a kind of a larger degree. So it makes sure that that mechanism, that feedback mechanism is active. Similarly as phentermine alone, similar potential side effects as well. Topiramate on its own can can cause a little bit of drowsiness. And so when it’s paired with phentermine, we typically don’t see that this is approved as a brand name medication.

00:25:22:17 – 00:25:58:05
Unknown
Sometimes we may give them separately depending on everyone’s favorite, which is insurance coverage, or I should say everyone’s least favorite hurdle. But it is something that we could give separately. In similar doses. The results were pretty good. So over about a year we saw close to 9 to 10 and a half percent weight loss from that starting weight and close to three quarters of individuals in this particular study saw that we reached that 5% target cutoff that we think of as effective weight loss.

00:25:58:05 – 00:26:23:12
Unknown
So Orlistat about a third phentermine topiramate close to three quarters. And this just presents that in graph form. You can see they actually did do what we call an extension study. They did it for a little over two years and the majority of that weight loss was maintained. You can see a slight uptick on those two bottom lines there.

00:26:23:14 – 00:27:08:07
Unknown
But overall, it was maintained a little after two years. That top line is no medication. Naltrexone and you on the brand name is country for that. This works in a slightly different way and our central nervous system still works on hormones that our body and our brain releases. One of them naltrexone. It works on the opioid receptor. One of the thoughts when this first came out was if someone has a little bit more of a component of that reward center causing weight, difficulty with weight, or someone maybe has a larger component of emotional eating, which we all do to some degree, maybe this is particularly more effective.

00:27:08:09 – 00:27:40:22
Unknown
I’ll explain in a second. May or may not be the case. This is pretty good. I’ll show you the results on the next slide. But of course, like with everything, some adverse effects, we can see that you see listed here. So requires close monitoring. The results were pretty good after close to a year, we saw anywhere from about six and a half to eight and a half percent weight loss from the starting weight, the green line and the triangles that was on the higher dose.

00:27:40:24 – 00:28:07:18
Unknown
So the highest dose that we typically try to make our way to after about a month or five weeks. Overall, though, in terms of percentages, not quite as good as the previous medication that I mentioned. So about six, six and a half when it was taken through beyond a year. So only about half of individuals reached that 5% of weight loss.

00:28:07:20 – 00:28:40:06
Unknown
The newer medications which have been in the news that you probably have seen or heard about or read to some degree, they’re all in what we call the glucagon like peptide receptor agonist class. So GLP one, you’ll probably hear that more often. But they basically this compound, this protein is released in response to food intake. It increases our bodies release of insulin, it decreases movement of our GI tract, specifically our stomach.

00:28:40:08 – 00:29:10:17
Unknown
So in that way we feel full a little bit quicker than normal. It also has receptors in our brain. So it’s working on appetite through our brain mechanism as well. The thing that is often not necessarily talked about is that receptors for this protein is pretty much in every organ system. And so it can have an effect on different organ systems that are doing a little bit more research about how chronic exposure to these medications may or may not affect other organ systems.

00:29:10:19 – 00:29:49:23
Unknown
So just to be aware of kind of the mechanism that we’re targeting when we did this for weight management but may have other effects as well. So in bold, those are the three in this class that are approved, FDA approved for weight management. The last one is actually a combined medication with this protein, along with the newer one, which we call GIP, or kind of briefly explain that, but just to be aware of reasons that we cannot give this medication, this specific class, there’s a certain type of thyroid cancer that we need to evaluate if it runs in the family, any first degree relatives.

00:29:50:00 – 00:30:24:06
Unknown
There’s something also called multiple endocrine neoplasia. It involves the thyroid gland, the pancreas as well. And so there are certain conditions that we can’t give that are involved in this multiple endocrine neoplasia history of pancreatitis or inflammation of the pancreas or gallbladder disease or infection stones, reasons that we need to be very cautious. Pancreatic cancer you may hear of as well if that runs in the family, that depending who you ask, we always proceed with extreme caution.

00:30:24:08 – 00:30:47:17
Unknown
If that runs in the family pregnancy like all of the other medications. And then because of how this works, we’re always cautious about the side effects nausea, vomiting, diarrhea, constipation, abdominal pain as well. Just to give you the results, to give you a sense of how they stack up against each other. So this was the first medication in this class that was approved.

00:30:47:17 – 00:31:17:04
Unknown
It’s a daily injection right now, and it’s actually still been on shortage from the manufacturer. So I would say we haven’t used it quite as much because it’s not available. But over close to two and a half years, they did an extension study anywhere from kind of 7 to 9% from starting weight. That bottom slide, which I didn’t circle, but you can see about half of individuals met that 5% target cut off.

00:31:17:04 – 00:31:49:06
Unknown
When we think of 5% weight loss from starting weight, this is just in bar graph form. So little bit over half reached that 5% in the initial study. The extension study I mentioned maybe close to half continued or maintain that weight loss. The two medications that are now used on a weekly basis, Semaglutide which is we’ll go be we saw that in the initial study, which was 68 weeks.

00:31:49:08 – 00:32:25:21
Unknown
We saw quite a higher percentage of those that lost, you know, close to 15% of weight from starting. So quite a bit higher than a lot of the previous medications they’re now doing and have come out with some studies looking at longer time periods. Is this weight actually maintained or what happens after the 68 weeks? We do know and this has also been in the news, we do know that if someone comes off of these medications and it’s really not unique to the injection medications, that we can see some weight gain.

00:32:25:23 – 00:32:52:17
Unknown
What I caution about this study in this graph actually is that it’s not really how we use the medication in practice. So that yellow orange line, everyone in the study got the medication and then they they basically randomized the top grade group, stop the medication. The bottom line, they continued the medication in practice, if we need to come off of medication because of the side effects, that’s different.

00:32:52:17 – 00:33:18:24
Unknown
We might just stop it. But if there is discussion with an individual and we decide together that, you know, maybe after two and a half years we want to come off, we usually wouldn’t just stop the medication, cold turkey. We would kind of gradually work our way down like we gradually work our way up. And the purposes, if we can prevent this increased risk of weight gain, of course, that’s our goal.

00:33:19:01 – 00:33:48:14
Unknown
So really good results In this study. You can see the right hand side, close to 90% reached that 5% cutoff. So quite a bit better than a lot of the previous medications, 15% total weight loss on average. That’s average. What’s important about the graph here, and I should have mentioned this with the other the other medications as well, you can see that, for example, 86% of individuals lost 5% from their starting weight.

00:33:48:14 – 00:34:22:04
Unknown
That means 13, 14% of individuals did. So it’s not effective for everyone. Fortunately, right now, we can’t predict two may not respond to the medications, but whether it’s with these injection medications or other medications, we do know that they’re not 100%. And that that goes with a lot of medications. There’s not necessarily one magic medication that works 100% of the time towards appetite, which is the brand name for the weight management medication is found.

00:34:22:06 – 00:34:56:00
Unknown
Also, really good results. A lot of information here, but the bar graph on the left, you can see with the different doses of this medication, close to 21% of weight that was lost from starting weight. And just at about 72 weeks, we see that 21, 22% weight loss from baseline close to 90%. So a little bit better than the semaglutide 90, 91% of individuals at the highest dose of the medication reached 5% of weight loss.

00:34:56:02 – 00:35:24:21
Unknown
And another caveat with all of these studies is the best results that are often presented and especially presented in articles that are available to the public. It’s at the highest doses. And I’ll say in clinical practice, not many individuals have been able to reach the highest doses for a variety of reasons. Side effects being a big one, insurance coverage or availability is another big one.

00:35:24:22 – 00:35:48:05
Unknown
Is it not available for one or two months? Then we’re kind of starting over. And so administration is a little bit scattered, something we have seen. So this is really, at least in the studies, the ideal scenario. So just kind of keeping that in mind. If any of you have spoken about these medications with any of your other practitioners.

00:35:48:07 – 00:36:20:07
Unknown
So this takes all of the medications that we sort of have in terms of options. And you can see over time, because this really correlates with when these were approved over time, we’re getting better with those solid red bars in terms of the amount of weight that can be achieved with the medications. Again, with the foundation that there are nutritional modifications, physical activity, behavioral modifications is really the staple prior to and while we’re giving the medications.

00:36:20:09 – 00:36:43:12
Unknown
So this is an important slide. You know, we’re making a lot of headway. As I mentioned, no medication is perfect, but I think at least we have some more options going forward. And again, kind of bringing it back in terms of uterine cancer, because we see that association with elevated BMI. Okay. These are going to be particularly helpful.

00:36:43:14 – 00:37:17:08
Unknown
Like with anything we do for weight, they’re a tool. So it doesn’t mean that they’re absolutely required. They can be an important step for some individuals. They don’t have to be a required step for everyone. But it is an option. And this just gives you a sense. There are a lot of different medications in the pipeline that they’re doing research on some work in the brain to a degree, some only work what we call peripheral tissues, whether it’s in fat, tissue, stomach, liver, GI tract or a combination of the two.

00:37:17:10 – 00:37:41:01
Unknown
But ultimately, like I mentioned, you know, medications are one additional tool. We know that we would not just stop a medication cold turkey, like I mentioned, if we can help it. So you can see the the green line there, that sort of the effect in terms of weight loss that we see with non medication interventions, medication can potentially add to that.

00:37:41:03 – 00:38:15:22
Unknown
So they are cumulative. They’re not just individually important. We know that both are important together. This is a really old study, but it’s all to kind of present that that lowest gray, light gray line there. We know that the most effective long term sustained weight loss occurs with combination therapy, lifestyle, nutritional, physical activity. And then if someone is a candidate for medication, that could be medication for this alone, it could be for other conditions for some people, surgery in the right setting.

00:38:15:24 – 00:38:46:24
Unknown
And then this is an important slide that I wanted to bring to your attention, because we are really starting to further individualize medication therapy, but also non medication intervention. So weight an elevated body mass index for so long and still in a lot of scenarios today, we thought, okay, BMI is high, let’s do the same dietary intervention exercise more that’s working or that’s not working through a medication.

00:38:46:24 – 00:39:13:06
Unknown
And for a while everyone is kind of grouped into this same bucket. And we know not just with weight, but every condition, there’s such variation. And this goes for uterine cancer as well, because there are different mutations, there are different receptors that are expressed. And so, as you know, different cancer types and different subtypes need to be treated differently for some surgeries.

00:39:13:06 – 00:39:38:12
Unknown
The first step for others, chemotherapy for others is monitoring or combination of the three. So we know with weight that same individualized approach needs to be taken. This study actually grouped individuals with elevated BMI, so some people were grouped into what we call a hungry brain. It’s high volume at a meal. So you eat two plates, three plates, four plates before you feel full hungry.

00:39:38:12 – 00:40:09:20
Unknown
Gut is you feel full shortly after a meal. So you finish breakfast. 30 minutes later, you’re hungry again. You feel like you need to. So that’s hunger and gut or a low level of satiety, emotional hunger again, which we all have. And there was some overlap and then slow burn, the prototypical person over 65 postmenopausal or short stature because metabolism is lower and so metabolism is just low compared to other individuals.

00:40:09:20 – 00:40:37:21
Unknown
So they actually gave each group a different medication. And what they found was close to 98% of people in the targeted group achieved that 5% weight loss, which you saw that didn’t, you know, none of the other medication studies was that 98% matched. So this is really the direction we’re moving in with medications. Can we further tailored type of physical activity?

00:40:37:23 – 00:41:08:22
Unknown
There are talks about how do we further sort of individualize type of nutritional pattern or should we say, these five items you shouldn’t have or you should have? We’re not quite there yet with food, but we’re working our way towards that. So body mass index, uterine cancer incidence recurrence, we know there’s an association, again, not causative, but we know that it’s important to kind of be in those lower ranges.

00:41:08:24 – 00:41:37:11
Unknown
5% of weight loss can be very, very beneficial. So everyone’s goal, short term, long term will be different. But just kind of keeping that in mind that 5% can make a big difference. We need to individualize it. Whether that means considering medication, medication. The goal ultimately with all of this is long term weight management. So I like to tell everyone and I like to remind myself that as humans, we’re not always built for patients.

00:41:37:13 – 00:41:59:22
Unknown
But for many of you, you know that that doesn’t mean if we lose weight in six months, that or great, everything’s fine. We want to make sure that we maintain it over six years and 60 years for some people. So that’s our always our goal when we consider medication along with the other changes. And then I mentioned individualizing approach.

00:41:59:22 – 00:42:16:23
Unknown
So everyone’s going to be a little bit different. That’s kind of the challenge. But also the joy of all of this that we all respond a little bit differently. And so there are many more options and there are going to be more options in regard to this. And and different strategies that we can use going forward.

00:42:16:23 – 00:42:28:03
Unknown
So thank you so much, Doctor Garcia. It’s wonderful to see that there is so much progress in this area and a lot of it in really recent years. So we’re going to start the Q&A.

00:42:28:03 – 00:42:53:11
Unknown
There were a bunch of pre submitted questions and you can still submit questions in the Q&A section at the bottom of your screen. And we’ll try to get through as many as as we can in our remaining time. So I’m going to start Doctor Garcia, if you’re taking KEYTRUDA and then Bima, because of a recurrence, can you take a an obesity medication?

00:42:53:16 – 00:43:27:21
Unknown
And if so, which one would be safest? Yeah, you can. And a lot of the hormonal or sort of targeted medical is usually not a contraindication to taking these medications. Side effects would be the potential biggest thing that they wouldn’t necessarily interact but just being aware depending how someone is tolerating those two medications and then of course, any other contraindications or reasons, we couldn’t give the weight loss medications I presented.

00:43:27:23 – 00:43:48:17
Unknown
But it really kind of depends the way I didn’t really mention this, but the way I approach considering medications is first, are there any we kind of have to just put it aside because of conditions or other medications. And then from what we have available, kind of having a discussion, you know, I think it’s important to discuss with the patient.

00:43:48:17 – 00:44:12:01
Unknown
You know, these are the side effects. If someone’s afraid of needles, maybe we’re not jump to an injection one. If someone has anxiety, maybe we don’t jump to those. So it’s really about the medications. You’re on KEYTRUDA, when Reema if you’re doing well with those, you could consider really any of the other ones, right? Thank you. I had a couple of questions to.

00:44:12:01 – 00:44:46:22
Unknown
This effect Are there any problems with using these meds and heart or high cholesterol issues? And there was somebody who wrote and their doctor recommended that they not go on a weight loss drug because of high cholesterol. Okay, great question. The heart you mentioned heart in the question. I, I didn’t specifically mention the stimulant medication. So phentermine phentermine topiramate combination and then there will be appropriate naltrexone.

00:44:46:24 – 00:45:21:17
Unknown
Those three can all increase blood pressure, heart rate. Typically if someone has a history of heart attack or they have coronary artery disease, sort of clogged arteries or have had a stroke, those three medications we really shouldn’t give if someone just has high blood pressure, but it’s well controlled, we could consider high cholesterol. Typically not a reason we cannot give if it’s just high cholesterol, because they shouldn’t affect cholesterol and they shouldn’t increase cholesterol in any way.

00:45:21:17 – 00:45:56:08
Unknown
But if you have other heart conditions, there may be instances where we really shouldn’t use those because it could further increase risk. Thank you very much. Somebody is asking about vitamins and supplementation with vitamins. Is that recommended as part of the overall strategy? It’s a great question. We actually just had a discussion and it’s it’s a it’s a whole nother probably 5 to 6 talks on its own.

00:45:56:08 – 00:46:42:20
Unknown
But what I would say, we know that the vitamin supplement arena is it’s very, very large and it’s growing. I think especially in the oncology world, we know that anyone that’s been diagnosed or has an increased risk, the use is probably higher than the general population. What I would say about vitamin and supplement use and this is kind of extrapolating from other cancer types because they’ve looked at certain vitamins such as vitamin E and selenium and vitamin A and supplementing it to either prevent cancer diagnosis or to prevent an outcome during treatment.

00:46:42:22 – 00:47:19:10
Unknown
And so the general guidance is if you don’t have a deficiency, there’s likely not a huge benefit to vitamins. If you do have a deficiency, we should treat. But if your levels are normal and we give you more potentially detrimental depending on the vitamin, sorry, I would not recommend it in that case. What’s unknown and challenging is a lot of the other non vitamin supplements, ginger, turmeric, you know, a lot of these other herbs that can potentially have benefit.

00:47:19:12 – 00:47:47:16
Unknown
We don’t have a lot of similar studies to say here’s the dose in a supplement, here’s what it can and cannot do. The other pieces supplements give us these these items in very concentrated amounts. So if anyone cooks with ginger versus taking a capsule, it’s just different. And we don’t always measure the dose when we eat it in crude, same with tumor or curcumin.

00:47:47:18 – 00:48:12:23
Unknown
So in general, if it’s a reputable source, that’s one thing we always worry about. Safety, too, is some of these can interact with chemotherapy and other treatments, traditional treatments for cancer, so that kind of plays into safety. And then three, sometimes we don’t know. So I would say going back in general, if you have a low vitamin, you may need supplementation.

00:48:12:23 – 00:48:43:04
Unknown
If you have normal levels, you probably don’t. And then for things that are sort of unknown, just making sure that you run it by someone in regards to considerations for safety, something I think patients offer to me because of this arena in terms of what they are taking. I know it’s not always shared because different practitioners view supplements differently, but I think, you know, the better approach is at least present it.

00:48:43:06 – 00:49:13:01
Unknown
It doesn’t mean one of your doctors may agree with it, but I think safety kind of being at the forefront is most important. Thank you. Yeah, that makes a lot of sense. Thank you. Please discuss these drugs as they relate to decreasing belly fat in particular. Sorry, can you say that one more time? Somebody is asking if you could discuss these these drugs as they relate to decreasing belly fat in particular?

00:49:13:03 – 00:49:45:08
Unknown
Great question. Typically with any degree of weight loss, everyone loses it in slightly different areas and different speed in general. We think that what we call the intra abdominal or fat around our typically that is lost first. So we may not see initial weight loss from the outside. After that, it’s a little bit different. So some people might lose it from their abdominal area or extremities or their face or combination of those.

00:49:45:10 – 00:50:25:01
Unknown
The newer injection medications. One of the ways that it’s thought they may work is how our body stores and breaks down fat. And so there may be a separate mechanism of action in regard to how it it may affect that storing and breaking down fat. So maybe not specifically to the abdominal area. So what I usually say, we can always target that specific area, but because we see a lot of fat deposit there and then in and around our organs, a lot of which are in that area, we tend to see at least some degree that’s lost there.

00:50:25:03 – 00:50:57:24
Unknown
But strictly from the medication perspective, we can’t target it based on this medication will preferentially lead to loss in that area. You we have a number of questions about BMI. If you’re overweight but not obese, how much is your risk of recurrence elevated of somebody else? Asked if they were of normal weight but want to prevent recurrence should they consider weight loss drugs?

00:50:57:24 – 00:51:34:20
Unknown
So I think just generally in terms of BMI, you know, what? Where would you look at What level would you would you start thinking about the weight loss drugs? Yeah, and it’s a really good question. And the best measure of excess fat is we do body composition measurements sometimes, and so that some of you may have those scales at home where you step on and it actually kind of passes on a light current around our body to measure how quickly or slowly that goes through different tissue type.

00:51:34:20 – 00:52:06:11
Unknown
So excess body fat is kind of the more important that may or may not correlate with body mass index. And so I think we we always take body mass index with a grain of salt. The associations that they saw started with over 25, but it was I wouldn’t say a very strong association, so maybe slightly increased risk, but within the error rate, you know, if you’re at 26.5 in, I wouldn’t worry too, too much.

00:52:06:13 – 00:52:43:03
Unknown
I don’t want to say that’s for everyone, but we know that 26.5 versus 3131, there’s a stronger association. So with each kind of point, we’re couple of points. That association has become stronger. So if depending on who you see, we always try to do body composition, that’s a better measure. If someone has a body mass index. 26 But normal body fat, I’m not you know, I wouldn’t do anything in terms of medication for weight loss because we need to get that into our normal range.

00:52:43:05 – 00:53:20:01
Unknown
Okay. Yeah. Thank you. This was a very interesting question that was submitted for a post-menopausal woman that had uterine cancer is use of natural progesterone or other hormone hormones content and indicated. Good question. Depends. I think a lot of the scenarios where it is used for potentially menopausal symptoms or there are other scenarios where it’s used. So depending on the indication for use, different cancer types might have different receptors.

00:53:20:02 – 00:53:52:01
Unknown
So estrogen receptors, progesterone receptors, we see that a lot. The different combination in breast cancer as well. And so it kind of depends. Supplements, while not supplements, medications that further activate those receptors potentially, we don’t want to give on our own. So we probably wouldn’t give estrogen medication or, you know, we might give the combination or progesterone alone.

00:53:52:03 – 00:54:26:18
Unknown
Estrogen in food is another consideration. We get the question about soy a lot, and soy or plant estrogen doesn’t activate our bodies receptors in the same way. So even estrogen and positive breast cancer, for example, eating soy doesn’t necessarily increase the risk of recurrence. So what I would say is the estrogen and progesterone medication or supplement potentially should not be used depending on your your characteristics of the cancer type and the subtype.

00:54:26:20 – 00:54:57:24
Unknown
So I think definitely something to kind of be aware of that there are scenarios we shouldn’t use them. Thank you very much. I did have one final question, which is and I know you talked about this and it was on your final slide, but what are your biggest takeaways for patients from this presentation? If you had to sum it up into something people can take away?

00:54:58:01 – 00:55:27:10
Unknown
Yeah, I would. Hopefully, when you’re navigating all of this because there is a lot of information and not to say that I or we know anything and everything, I think there’s so much information out there it is hard to navigate, especially when we take news articles which like with everything, you know, there needs to be headlines to kind of catch your readers attention, you know, navigating that versus maybe what the studies show.

00:55:27:10 – 00:55:59:05
Unknown
And then when we look at studies, how does that actually apply day to day to, you know, you and the next person? So what I would say is with all of this, like you guys are doing and again, I’m glad that you invited me to to speak, I think talking with some of your practitioners, your doctors about this and asking these same questions, because I can give you some general information and some, you know, hopefully applies to some of you in various ways.

00:55:59:05 – 00:56:32:23
Unknown
But ultimately, it really does depend on your individual medical history and characteristics, your family history, other medications you’re on, what dietary pattern you eat, what activity you do. So there are a lot of different variables that go into this. And many others we didn’t even talk about in your sleep and stress and smoking. So a lot of different factors that ideally we tailor them into your specific situation that will be most beneficial for you.

00:56:32:23 – 00:57:02:02
Unknown
It’s not it doesn’t mean it’s perfect where we can take your characteristics and tailor it perfectly. But what I would say is, is doing what you’re doing, asking the questions. It is hard to navigate even for people that don’t do weight management. So ask the questions, have the discussions. If you’re unsure, ask more questions and like I tell everyone because we’re all different.

00:57:02:02 – 00:57:28:22
Unknown
What works for some one person doesn’t work for the next and vice versa. So if you are doing well with weight loss, great. Keep it up. If you’re not, doesn’t mean you’re doing something wrong. It just means it needs to be adjusted a little bit. Thank you very much. It’s wonderful that there’s a specialty like yours to really work with people in an individualized way and really help them with these issues.

00:57:28:24 – 00:58:05:17
Unknown
So we really appreciate your your taking the time. This was really interesting and informative and thanks to all of those who participated with questions and joined us tonight. Please make sure to check out shares, upcoming educational programs and support groups and follow us on social media as well. I also wanted to mention, since it’s apropos to tonight’s topic, that we share partners with AYANA, which is an app which is called Intelligent Nutrition Assistance.

00:58:05:17 – 00:58:26:21
Unknown
And once you sign up, it’s totally free. You can communicate with AYANA 24 seven to receive personalized, clinically appropriate and on demand nutrition support and guidance. So I encourage you to check it out. It’s really a terrific app and the URL is listed on the slide now.

00:58:26:21 – 00:58:38:04
Unknown
Thank you again, Dr. Garcia, and thank you to everyone for joining and have a good rest of the evening. Thanks everyone. Take care.