Is Ozempic the Wonder Drug, or the Drug You Should Wonder About? with Dr. Mariam Manoukian

Dr. Furnas (00:10):
What is Ozempic face and why is social media driving the demand for this weight loss drug? Stay tuned as we welcome our special guest, university Medical Partners, Dr. Mariam Manoukian. Welcome to Skin Tuition. I'm Heather Furnas.

Dr. Korman (00:29):
And I'm Josh Korman. From Pimples to Wrinkles, our skin effects how we feel about ourselves as two plastic surgeons. We discuss what's new, what's safe, and what to look for when you're ready to hit refresh. Dr. Mariam Manoukian is a renowned internist and endocrinologist who has many years of experience treating patients with obesity, diabetes, and metabolic diseases. Welcome Dr. Manoukian.

Dr. Manoukian (00:58):
Well thank you for having me.

Dr. Furnas (01:00):
So tell us, Dr. Manoukian, what is Ozempic?

Dr. Manoukian (01:04):
Well, Ozempic is otherwise known as semaglutide. Uh, is medication that is produced by Novo Nordisk, but it's actually an analog of glucagon-like peptide. So first of all, I just wanna mention that I have absolutely, I'm not sponsored by Novo Nordisk and I have no actual interest in these drugs except for certainly using not just Ozempic but other GLP ones in my daily practice. The GLP ones or glucagon-like peptide is a hormone that is produced by our own intestines and it's affects our, most importantly, it's produced to not improve, but actually to kind of, uh, put the glucose into the right place. It stimulates insulin production. It's like starts that machine of when glucose goes into the person's mouth. So some brilliant people, you know, some years ago figured out that there is actually, we produce hormones that can affect not only the whole glucose production machine, but also affects our appetite. And those eventually turned into this medications that are, you know, they actually, the hormones are called incretins, but they kind of started to separate each one of them. And the first one that came on the market was the GLP one. It came as several different medications and most recently the very famous Ozempic.

Dr. Furnas (02:44):
I'm gonna ask you to back up. So if I take something to eat, I eat something, my food is digested. And then you mentioned glucagon and insulin and glucose. Can you kind of take us through that?

Dr. Manoukian (02:59):
Yeah, sure. So when a person starts eating, actually anything, not just glucose, but it's actually the production is insulin, uh, the glucose dependent, but anything we put in our mouth, it doesn't have to go down all the way to someplace to start. The whole mechanism of the so-called metabolism in the intestines. The production starts of these hormones that start moving things around like the pancreas produces insulin, even without seeing that glucose yet in the bloodstream. It's actually fascinating. And once the person, the hormone starts being produced, it starts telling the brain you are eating. So everything starts going in the body and then once the person is eating some more, then the brain actually starts telling us you have eaten. So that is actually the satiety that we call a satiety because I'm eating and then suddenly I feel like, you know what? I ate enough, I have to stop.

(04:07)
So what we noticed in diabetes and obesity is that this effect is lost. When they first started to find this out, they thought that there is a deficiency in this GLP one s, the satiety hormones, but then they found out that there might not be a deficiency, there might be a resistance. So in people with obesity and diabetes, the effect of this GLP ones or incretin or Ozempic or whatever you want to call the satiety hormones is missing. So hence the suddenly that we get this medicine in our hands that is causing satiety becomes so important.

Dr. Korman (04:50):
So how much weight can people lose and over what period of time?

Dr. Manoukian (04:56):
It varies, certainly, and I'm sure that we are seeing from some small weight loss to up to 70 pounds. I've seen people losing, with time, one of the best things about this kind of medications is that people continue to lose the weight. And one of the reasons is because we have also the dosages are you can go up on the dose once the person notices that, you know, they're stuck in a sense. So the weight loss can be, I mean, like I said, I've seen 70 pounds. I'm sure there are people who lost more, but the interesting thing is pretty much everybody loses weight, which is I think is again, is one of the very important things on all the other weight loss drugs that we had before. Not everyone lost the weight and you know, people would lose 5% or 10% most of the weight.

Dr. Furnas (05:50):
So do they lose weight until they reach an ideal weight? Can you overshoot or how does it work? You mentioned the satiety, so you're satiated, you've had enough and so you should reach a resting point where you are eating normally. Is that right?

Dr. Manoukian (06:08):
Yeah, yeah. I think, well, eating normally is kind of a, there is, you know, it's normal for different people would be normal differently. And it depends on their resting metabolism, it depends on their activity level and you know, there are many factors, but yeah, certainly the main mechanism is basically eating less. And uh, frequently people would come and say, oh, I can't eat any less. You know, I'm eating so little and I'm not losing weight. Well guess what? When they start on Ozempic or the other GLP ones, they start losing weight because they're eating less because every person thinks that they're at their minimum eating, but the, at the end of the day still they eat more than they should be.

Dr. Korman (06:54):
So that's actually really interesting and it brings up a question of what is the measure of obesity? Because obviously people grow up in families where different weights are culturally accepted, not accepted. So what do you use as a measure of obesity?

Dr. Manoukian (07:13):
That's actually a phenomenal question because first of all, you know, we have these numbers, right? You know, you know the body mass index that we call obesity. When a body mass index is above 30, we call people overweight. If they are, their body mass index is 25. But is this true for white people, for Asians, for Hispanics, and plus we have all these thin models that everyone wants to be thin. It becomes really complicated. To me, obesity is when people feel like they're overweight, that it impacts their daily life. It creates a lot of other diseases. Like we know that obesity is a precursor to diabetes, to heart disease, to all kinds of, uh, joint pains to all these knee replacements, all this and of course, depression, first of all, until 2013, US did not recognize obesity as a disease, which is absolutely ridiculous. If you coded as physician, if you coded a person with obesity code for a C P T code, insurance would not pay because it wasn't considered as a disease.

(08:22)
So finally we said, fine, this is a disease just like blood pressure, just like diabetes. Finally we came up with the idea, hallelujah, that obesity is a disease. It's not like people are doing this to themselves and they should stop doing it. But what is the actual mechanism? Of course, partially it's genetic. It's of course environmental what people eat. You know, a lot of people who are like Bill Mar, he thinks like if we eat less then everything will be solved. 40 years ago we didn't have obesity. It's all our fault. It's the fault of the people who put too much sugar in the drinks. Too much drinks have gotten bigger. So there are many, many causes of obesity and certainly why is it that US is the most obese country in the world? Why is it that we have 40% of obesity versus France has 17% and Japan has only 4% of obesity.

(09:18)
So there are so many factors that are involved in this, but very important for us to understand that obesity is a condition that it's a medical illness, it's a disease, and it's both physical and it's both mental because every obese person knows that it's not good to be obese, but they're still eating and they're still gaining weight, right? So it is not just a simple one physical condition. So I think that for us, having finally medications that are truly improving the condition, I think this is just basically revolutionary. And like I said, you know, for me as a physician who's been treating diabetes and uh, type two diabetes and obesity for so many years, I'm really happy to have this medications on the market.

Dr. Furnas (10:09):
You know what's interesting is that there are a lot of people who are on social media in celebrity circles talking about Ozempic and similar medications for not weight loss when they are obese, but more an aesthetic range, 10, 15, 20 pounds. Now, what is your feeling of that?

Dr. Manoukian (10:32):
I see that all the time in my practice too, when you know, you almost want to tell the person, Hey, come on, you're not obese, you're not overweight. Why are you even worried? But again, this comes this mental component. I mean, not so much men certainly for this kind of weight, but women, you know, during menopause or you know, they gain some weight and then it's extremely hard to lose the weight. I personally think that there is absolutely no problem using the medications. I'm certainly not turning them into some skinny models, but getting a read of the abdominal fat and letting them use, having them lose those 10 pounds that they've been struggling for a long time, I think that's a great idea. I don't see any problem with that.

Dr. Korman (11:20):
So in that context of when would insurance cover the medications and when would they, insurance companies say this is more of an aesthetic rather than a medically necessary treatment. And in your practice, how do you work with that? And if patients have to pay for it by themselves, how much does it cost?

Dr. Manoukian (11:46):
Well, obviously the medications are very expensive, but they're all brand medications, so they're quite expensive. The two companies that make them, the Novo Nordisk and Eli Lilly, both brand medicines, both have been on the market for many years with uh, great drugs for diabetes. So medication, right now, all of them are covered by majority of the insurances for diabetes. For obesity, they're covered if the body mass index is above 31 or people have any medical conditions, which are, you know, depression, asthma, sleep apnea conditions that are actually directly are related to obesity. So it all depends on the insurance. A lot of them, the coverage is not that bad truly, but sometimes some insurances would just absolutely not pay and I would not understand that for people who's B M I is above 30 for people between 25 and 30, that's a matter of a luck in my experience.

(12:52)
Sometimes insurances will cover and they probably have some premium insurances, sometimes they won't. It's really hard for people I think, to pay for those. I think they're quite expensive. They're usually around thousand dollars a month, you know, as you know, there are all these companies that somehow get this medicine and distribute and that's another whole big market that I see. And I'm not sure, I've talked to the companies and they're saying that they do not promote those companies. So it's not clear really how the spas and the, you know, a lot of the places where these medications are given to patients in syringes. I honestly don't have much comment on that.

Dr. Furnas (13:37):
What are the side effects to these medications?

Dr. Manoukian (13:41):
So any patient who opens the patient PI, the patient information, they just first shock is that it causes thyroid cancer. But the type of a thyroid cancer that is mentioned in the PI is called medullary thyroid cancer, it's extremely rare and it's only shown in rats. So that really is irrelevant. However, because these medications are causing uh, satiety, they will give some nausea and some people have constipation, rarely diarrhea. Those are the most common side effects of the medications. Amazingly, they're tolerated pretty well. Amazingly I have, I don't know, maybe one in a hundred patients would say I can't take it because it gives me too much side effect. The long-term side effects is a question, you know, but for that's clear, you know, for all of us working in medical field, we know that unfortunately a lot of medications are used for many, many years and then somebody finds something about those. I mean, so far it looks like it's very benign. It's certainly a risk and benefit anytime you take a medication.

Dr. Korman (14:51):
So that brings up a an important question, like how long should or can people stay on these medications?

Dr. Manoukian (14:59):
In my opinion, probably for a long time or forever, for people who suffer from obesity for many years, I think it's like we treat blood pressure for 25, 30 years. It's possible that it needs to be treated for 25, 30 years. I don't know, whatever, how many years, uh, people need it. But for some people it is possible that with the changing of their lifestyle, with doing their habits change, they notice how much they eat, what they eat, what creates, certainly if they are in addition starting to exercise or making the exercise as a part of their daily routine and changing their habits. You know, I certainly hope that for some people it's going to be like, particularly those people that you're talking about 10, 15 pounders who need to lose only that it's possible that they would eventually not need it. I mean, that remains to be seen.

Dr. Korman (16:00):
Or maybe it's a little bit like people who try to use liposuction for their method of weight loss, like they have it, then they don't, you know, after a bunch of years they come back again cause they've gained some more weight and wanna do it again. You know, maybe that's how it's gonna be with these medicines that they'll use 'em in. Are are these pills or are these injections?

Dr. Manoukian (16:20):
No, no, they're injections of course. Yeah, it's a once a week injection that is actually you need to increase the dosage because at a higher dosages is, anyway, that's another issue that people notice that when they stay on the same dosage for several months, then it stops working. There is some resistance, but we see that with blood pressure. You know, we see that with diabetes, it's nothing surprising.

Dr. Furnas (16:46):
So what do people do when they inject it? They inject themselves? Is it in the skin or deep into the fat?

Dr. Manoukian (16:54):
You know, it's written on the patient instructions and it's usually, you know, inch or two away from the belly button. You know, usually people have a lot of, you know, those of you who have done surgeries, you've seen how much fat we have there, right? <laugh>, even the thinnest people have some fat there. So injection is subcutaneous. The Ozempic pen actually itself is a very high quality pen and the injections are totally painless. Wegovy which is what we need to mention, that the same compound, same molecule that is called Ozempic and is used in diabetes, the same compound is called Wegovy and that is the one that is approved for obesity. And the pens are slightly different for people to understand that the company took the same compound and called Ozempic and is using it for diabetes. It called Wegovy and that is approved for obesity.

Dr. Korman (17:53):
So it sounds like you like these medications a lot, that they really do help a lot of patients.

Dr. Manoukian (18:00):
I do, I do because I see for the first time that I make a big difference in patients lives. And I used to have a weight loss clinic that was called a 52 week weight loss clinic and uh, closed it because I felt like I cannot help patients because by teaching them how to eat, how to exercise, hiring a cook, nagging them every week, checking them at the end of the year, first of all a lot of people dropped out because they weren't, they lost some weight and then they gained the weight back. We've seen this with every single weight program, you know, people lose some and if you nag them all the time, you might have some success. I'm certainly extremely against all the liquid diets that have been used. Yes, people lose weight and then all that weight comes back. Now is this gonna have the same fate if you suddenly tomorrow all the Ozempic or Wegovy disappears off the market? I don't know. Because this is a chronic disease, you cannot just treat it for five minutes and then expect the benefit forever. That's what the patients need to understand that there is nothing that I lost the weight and it's gone. No, it's a chronic condition. It's a chronic medical disease that needs to be constantly treated. And the lifestyle is a treatment. It's not just the psych stuff. Eating healthy and exercising is a a way of treatment. But so are this important medications of course.

Dr. Furnas (19:34):
There's another medication, Mounjaro, how is that different?

Dr. Manoukian (19:39):
So like I mentioned, Ely Lilly is the other company that makes the, and Ely Lilly made this Mounjaro, which is again a GLP one and plus they added another satiety hormone that is called G I P. Also very successful medication. Right now it is only covered for diabetes. And I certainly absolutely like the way it works because you can't do anything better than help the type two diabetic to lose weight. Because for years and years and years we treated type two diabetes to this number, which is called A1C, to improve their A1C with any means and the any means meant insulin and all the drugs that help these people to gain weight and gain more problems from the weight. So finally we have medications that actually helps them to lose weight and frequently reverse diabetes, which is, oh my god, you know, we're finally doing exactly the right thing. <laugh>.

Dr. Korman (20:43):
So let's expand it a little because from what I've read, not only do these medicines clearly help with obesity and diabetes, but they actually may help with other things like anxiety or depression. What have you found?

Dr. Manoukian (21:01):
Yeah, so because obesity is this very complicated physical and mental condition, the way this vicious cycle works in people is that they're trying to eat healthy, they're trying to eat healthy, they're trying to eat healthy, and then nothing happens. You know, because their healthy is a lot more food. Like I can't tell you how many times I hear from my patients, my problem is the, you know, morbidly obese person. Why do you think you have so much weight? Because I don't eat enough protein. No, that's not the problem. The problem is that people try to fix their eating, nothing happens. They don't lose the weight because they're still eating too much. They maybe eat less than what they thought and then they don't lose weight. And then they extremely depressed. They have the sugar blues, they eat the sugar and then they gain the weight to gain and then they're so anxious, they're so unhappy.

(21:58)
So a lot of the obese people are very anxious, you know, very depressed. I had a patient who said she could not listen to her child playing at a Carnegie hole because she saw some cookies outside of the hole that she had to go and get those cookies. You know, it's a severe addiction. So what Ozempic does, what, you know, GLP one s do, they basically get rid of those addictions and that's a such a relief for people. It's finally, you're not addicted to food. They take the food out of their focus and that makes people very happy. So, you know, not only when I see people who have lost, uh, quite a bit of weight, they're happy because they can exercise, they can walk up a heel, they can run upstairs, they can do things. They're also feeling very relieved because they don't have that terrible vicious cycle I'm gonna eat, then I'm gonna blame myself, I'm gonna try losing weight and then that doesn't happen and I go eat again. I think that having that cutting, that vicious cycle is what these medications do. And that helps with anxiety, it helps with depression. There is actually other phenomenal data that shows which is well known, which helps with heart disease. You know, it's a cardiac protector because of the weight loss or because of whatever other reasons, but it also helps with lowers the heart failure, you know, it's, it does other positive things to the body.

Dr. Furnas (23:32):
Now there are other addictions that it may help with, like alcohol and even shopping, online shopping? <laugh>,

Dr. Manoukian (23:39):
I read about that too, and I see that in my patients too. I did not realize that a lot of these addictions, well first of all, we know they're very connected and they light up the same centers in the brain. The addictions are very similar. So I've read about that too, that it can help with the shopping addiction or with, certainly it would be interesting to see, I mean a lot of the obese people do not smoke, so their addiction is to food, not to smoking. And kind of in a sense they're all addicted to different things. So,

Dr. Korman (24:16):
So we started this show by mentioning something called Ozempic Face, which is getting a lot of press in the social media world. What, what have you found with that?

Dr. Manoukian (24:26):
You know, interesting enough, I mean I certainly, I'm assuming that people have saggy skin after weight loss. That's what's the Ozempic face is probably, and I've seen that a lot in when people lose a lot of weight. Now, again, this is my personal experience and that I do not see that as much because the weight loss is, it's just such a beautiful weight loss in a sense that people lose two to four pounds a month. So there is time for the body. It's not like the after what we see with the weight loss surgeries, when I'm talking about 70 pounds, I see that in a year it's not happening very quickly. You know, just people notice how well they feel. That is what we noticed. So honestly, I don't have much, I haven't seen any Ozempic face in my practice, but I would think that when people lose weight, they would be interested in fixing the skin, just like in other weight losses or not <laugh>.

Dr. Korman (25:35):
I know I find in my practice that, as you mentioned, the massive weight loss surgery, the bariatric surgery, the body does not have time to recover and so the quality of the skin is damaged so that it's the elasticity is gone. Whereas if people lose a lot of weight through their own diet and exercise, which I guess that's what this is, this is sort of an accelerant to the diet and exercise, that it's much easier to do surgeries on them that create significant improvement. The massive weight loss surgery also, clearly there's a lot of skin, you take it off, but it certainly seems more logical. Heather, what have you found in your practice?

Dr. Furnas (26:16):
Yeah, the massive weight loss surgery patients. A tissue is always different. Blood vessels remain very large, so bleeding is an issue, but nutrition is an issue, particularly depending on the type of massive weight loss surgery. And these patients need to take supplements. Sometimes they don't heal as well simply because of the absorption. So Dr. Manoukian, I wonder if these medications replace massive weight loss surgery?

Dr. Manoukian (26:46):
Absolutely. Absolutely. I think it should actually. There is gonna be some room because you know that there is a kind of a type of a genetic obesity, there still might be some room, but you know, before I used to refer a lot of people to weight loss surgeries, this newer weight loss surgeries. Certainly the what we are talking, I guess what you've seen most people had the ruin y surgery. You know, the more gastric sleeve is kind of a less nutrient kind of a, people still absorb the nutrients because the most of the small intestine is, uh, remains. But I think that it, these medications will help us to avoid the surgeries. And they're actually used in children now in younger adults, which I think is great because we always think we shouldn't do, the kids should do this, should do that, they should eat healthy, their parents should be this and that. But at the end of the day, we have a major obesity problem in children. So yes, I'm hoping that with using these medications and learning more, I'm hoping that more is gonna come, you know, with this, now that we figured out that we have this GLP one s and that, you know, 30 years ago no one had any idea about this mechanism. So I think that absolutely it should be replacing right now and for, you know, <laugh>.

Dr. Korman (28:11):
So what, in your experience, and I don't know if it's been around long enough to know, but what happens when people who are on these medications stop? Is it something they should stop gradually? They should stop right away and what happens?

Dr. Manoukian (28:29):
I'm sure there is some data, you know, I'm sure pharmaceutical industry has some data. Sometimes it's going to happen. I don't know, honestly, I cannot answer that question. I can tell you from my experience, knowing that this is a chronic disease, I think that in a lot of people the weight is gonna come back Now is it gonna come back fully or it's gonna come back lessons. Hopefully they brought those new techniques into their life that they've started to love exercise or you know, people who exercise in general will do better no matter what that is. But a lot of people who are overweight, exercise for them is a torture. They just are not used to exercising and telling them about, at least starting something. I'm hoping that exercise and lifestyle and for them to understand, they should not be drinking soda. They should not be eating too much meat.

(29:25)
They should not be eating sugary foods and fried foods and fast foods. You know, all these things that we've been saying before. Hopefully now they notice that since there was a hope, they finally, it worked. Hopefully they've implemented these changes, but that the weight will come back. I have no doubt that some of it will come back. Now for people who lose just those five, 10 pounds, maybe they can keep that off. You know, we have to see, we have talked to me in a year. I'll definitely will know <laugh> the answer to that question because sometimes the patients run out of medication and I try kind of teaching them how to maneuver a little bit, you know, how to stretch the dosage into two weeks instead of one week. How to play around with the medications. But you know, we have to see what happens because a lot of people would like to stop it. This is in people's mind that, you know what, I'm gonna lose the weight and I'm gonna be fine. So we'll see.

Dr. Furnas (30:30):
And what are the programs like with children? Do they anticipate these children will be on these medications lifelong? Or is there an attempt to make it short-lived?

Dr. Manoukian (30:41):
Yeah, you know, I don't know, but right now the children are for a long time on the medications. And certainly again, like in children, that change is probably easier to achieve, hopefully by changing the lifestyle and teaching these kids, of course, it's hard to imagine that someone needs to be 70 years on a medication. Right? Yeah. Hopefully not <laugh>.

Dr. Korman (31:04):
Okay. That's tremendous. It's wonderful. Is there anything else you'd like to include?

Dr. Manoukian (31:10):
Well, again, mentioning that I'm not absolutely, this is not a promotional talk. I just wanted to share with you the difficulty in general treating all of these conditions. You know, and I know that you being in plastic surgery probably have seen that too. It's really a condition that is really, really hard to treat and people wanna be thin and they wanna look good. And for that, it's one side of the story, but the other side is all these medical illnesses that come from the weight. And I'm just very excited that we have that now that we help people to lose weight, to actually reverse diabetes. You know, these are, we can call them diabetes, reversing drugs. So exciting, exciting times.

Dr. Furnas (31:57):
Thank you Dr. Manoukian, it's been a pleasure to have you. This is Skin Tuition. I'm Heather Furnas.

Dr. Korman (32:05):
And I'm Josh Korman. And we'll see you next time.

Dr. Manoukian (32:09):
Bye bye.