Empowering Health: Navigating Obesity Medicine, Medications, and Advocacy with Dr. Asma Al-zougbi

Welcome to the Get Healthy Tampa Bay Podcast with Dr. Kerry Reller! This week I am joined by Dr. Asma Al-zougbi to discuss the challenges of weight management, the evolution of obesity medicine, and the crucial role of medications. They emphasize the need for insurance coverage advocacy, share practical advice on nutrition and exercise, and highlight the significance of open communication in patient care.

Dr. Asma Al-Zougbi is a board certified endocrinologist and the Medical Director of the Tampa Endocrinology Institute, offering one-on-one personalized endocrine care. She completed her fellowship in Endocrinology, Diabetes and Metabolism at the University of Iowa in 2017, where she also completed a Master’s degree in Medical Education in 2019. It was during fellowship that she shifted her focus to weight management, helping relaunch the weight management clinic at the University in 2019. As part of her interest in metabolic health, she also completed two years of basic science research, studying skeletal muscle atrophy in different mice models. She moved to Tampa in 2021, and has been serving the local community since then. When not in the clinic, she can be found trying not to pass out at CAMP Tampa or with her family at Gracie Tampa South and the Roy Jenkins Pool.

0:00  Welcome back! Guest Intro
0:47 About Dr. Asma
3:16 Evolution of Weight Management Tools
6:22 Challenges with Insurance Coverage
7:58 Advocacy for Medication Coverage
11:14 Impact of Obesity on Different Demographics
11:48 Issues with Affordability
12:18 Patient Empowerment
13:32 Individualized Approach
16:20 Approach to Medications
23:36 Discussion on Dietary Guidelines
24:26 Exercise and Importance of Preserving Muscle Mass
26:03 Connect with Dr. Asma, Closing Remarks

Steps to take when Medications (or Surgery) for Obesity are denied:

1. Send patient to: https://www.obesityaction.org/advocacy/resources/access-to-care-resources/, and have them complete "OAC's Report Issues Form," which is linked ~ halfway down the page.

2. Have patient reach out to their employer's HR department, and make sure that they are aware that the policy doesn't cover treatment for obesity. Patients may be able to request for individual coverage for treatment OR that their employer expand access for all employees to receive treatment. There is a copy of a sample letter to request coverage on the OAC's website as well.

3. At Open Enrollment, ask patient to investigate options and specifically select a plan that covers medications used to treat obesity.

Connect with Dr. Asma
Website: https://www.tampaendocrinologyinstitute.com/
Email: al-zougbi@tampaendocrinologyinstitute.com
Phone Number: (813) 360-1214
Facebook: https://www.facebook.com/profile.php?id=100085222024528
Instagram: https://www.instagram.com/tampaendodoc/

Connect with Dr. Kerry Reller
My linktree: linktr.ee/kerryrellermd
Podcast website: https://gethealthytbpodcast.buzzsprout.com/
Facebook: https://www.facebook.com/ClearwaterFamily
Instagram: https://www.instagram.com/clearwaterfamilymedicine/
Clearwater Family Medicine and Allergy Website: https://sites.google.com/view/clearwaterallergy/home

Subscribe to the Get Healthy Tampa Bay Podcast on Apple podcasts, Spotify, Amazon music, iheartradio, Stitcher, Google Podcasts, Pandora.

#WeightManagement #HealthJourney #WellnessPodcast #ObesityMedicine #MedicalInsights

Transcript

Kerry: 0:29

Hi, everybody. It's Dr. Kerry Reller. Welcome back to the Get Healthy Tampa Bay podcast. Today we have a very special guest, Dr. Asma Al-zougbi. Welcome to the podcast.

Asma: 0:41

Thanks for having me.

Kerry: 0:43

And can you introduce yourself and tell us who you are and what you do?

Asma: 0:47

Sure. So I'm Asma. It's very nice to meet you. I am a board certified endocrinologist. I practice out of South Tampa. I have my own little clinic where I do general endocrinology, but with a focus on obesity medicine. graduated from the university of Iowa. That's where I did my fellowship. And then that's where I started getting interested in obesity medicine actually, because when I went into endocrinology, I didn't know that that was an option or part of what we covered, but yeah I, it was just perfect because at that time they were starting to reopen their weight management clinic. They had had one before, but it had flopped for some reason. And They were, yeah, they were reopening it. And so I was part of that revamp. And it was very educational. And so when I had the opportunity to open up my own clinic, this was exactly what I wanted to do. I wanted to do weight management. And you and I have been in the field for a while. We've been, I mean, I've been doing it since around 2017. How long have you been doing it?

Kerry: 1:53

Not, not as long as you I found it definitely later. Like you said, you didn't know it existed. So obesity medicine, I think it's just kind of something that I had come across, but realizing that we are like in primary care coming across these problems all the time and everything is interrelated. So getting at like the root causes, you know, very important and helpful. So it sounds like you found it a lot before me, and that's wonderful that you, were introduced to obesity medicine in fellowship. And part of their program. So that's wonderful. And you've brought it to your practice in Florida. Now, are you insurance or cash based?

Asma: 2:26

I am cash based, but I also accept Medicare Part B. but if patients have insurance that they can use their insurance for labs and meds and imaging, et cetera. What I wanted to say is back in 2017, we really didn't have much. In terms of weight management tools. So we all know that the basis of weight management is, what you eat, your activity levels, your behavior. So that's the foundation of any weight management program that is legit, right? There's a bunch of these, especially now these pop up, you know, med spas. Come, I'll give you an injection. I won't talk to you about diet or exercise, but just come every week. I'll give you an injection and you'll be fine. Which is really not the basis of a healthy life or a healthy body, right? Do you agree with me?

Kerry: 3:16

Yes. No, I do agree. And in our area, I am seeing a lot of that. And it's unfortunate that, they may get their medication, but they're not getting the education and guidance and support that they really need to make the changes if the medication isn't there or available. And that's what is kind of a big unknown right now.

Asma: 3:35

Totally. Exactly. And so that's always been the foundation, but as you and I know patients with obesity, their body is fighting them so they can try as hard as they want to in terms of sticking to the meal plan, exercising, saying, no, no, I'm not going to eat the sleeve of Oreos at night, et cetera. You know, for examples, you know their body is fighting them. And that's where the medications come in for some patients. Of course, a lot of patients can do it without the medications, but the medications have just been so helpful. So back in 2017, we only had one GLP 1 agonist and the GLP 1 agonists are, like Ozempic, Wegovy. These are the, everyone suddenly now knows about these medications, but back then we only had Victoza, which was a once daily injection. In terms of that class for weight management. And we did have the pills, which we still use right now, right? We Qsymia, Contrave, et cetera. Those have their place, but they're just, not as effective as the new GLP one agonists. And so back then I used to struggle a lot cause I talk about the diet. I talk about the exercise. I put them on these medications. In fact, I had one of my patients, I had him on I think four different anti obesity medications. Literally, he had had a gastric bypass years before and had failed basically. And he had very significant osteoarthritis because of it and they wouldn't do his knee replacements because he was too obese and he was young. He was in his forties, and he has kids and he was like, you know, I can't go do stuff with my kids. I'm just stuck in my body. And so I literally had him on 4 anti obesity medications including phentermine. the interesting part about this is that when we left, this was back in Iowa. I practiced there for a couple of years as staff, and then I left and my colleague picked him up and I bumped into my colleague this year at the endocrine conference. And he was like, Do you remember that patient? He says hi, and he says thank you, because His knees are so much better. In fact, he didn't even need the knee replacement.

Kerry: 5:43

Wow. That's amazing.

Asma: 5:45

is amazing. But those success stories, at least for me, were rare because we didn't have such amazing medications. And then, you know, a few years ago, Ozempic slash Wegovy came out and it was such an exciting time. We had heard, the murmurs, the rumblings in the obesity world that a new class of medications is coming out. It's going to be a game changer. And when they actually hit the market. It was like night and day, you know, they're amazing medications, but the issue is, as I'm sure you know, is insurance coverage.

Kerry: 6:22

yes.

Asma: 6:23

insurance coverage has been very difficult, very, very difficult because these medications cost around a thousand dollars per month, which is a huge amount. And getting insurance companies to cover them is very difficult as well. I don't know of any studies that have shown the cost benefit of covering these medications. I've looked for them. I haven't found them.

Kerry: 6:45

I don't think that they can really do that analysis properly right now, because this is going to be long term information, right? They are potentially treating, reversing, preventing multiple diseases and multiple comorbidities that are involved with weight. So. I mean, if the person is already diabetic, they may be having better access to the medication and they have the ability to prevent, cardiovascular disease and things like that, that are always associated with diabetes, but for just weight, we don't know, like, how are they going to do those studies? I don't know. But I mean, think about the like lifelong things that can happen that are weight related. You mentioned a knee replacement, right? I don't know. What is the cost of that? Like all of these things add up, and eventually end of life care too, which usually stroke or heart attack, they could be in the hospital a long period of time. That's where a big bulk of healthcare costs too. So, I mean, potentially that could even be prevented. I have no idea how they would do a cost analysis like that, but I do think it's possibly in their favor to at least, get the prices down a little bit. And then it could be potentially cost beneficial to have them on the drugs, even if they are that expensive for every month.

Asma: 7:58

So the issue is also or at least I tell my patients talk to your employer. If this medication has been denied, talk to your employer because it's your employer that negotiates coverage with your insurance company. These days, talk to your representative. Talk to your legislators. There are people in government talking about this, and you need to let them know that you care enough to write a letter to them, and if you are on the medication, tell them how great it is, and if you want to be on it, tell them how obesity has affected your life. The issue, really the underlying issue, is that obesity is not widely recognized as a disease anD until we recognize it as a disease, it's going to be very hard to to get coverage for medications for a non disease, right? Right now, everyone, or the prevalent thought is that Obesity is an issue of lack of control. Control yourself. Your insurance company shouldn't have to pay for your willpower. You need to fix it yourself. This is not a disease. But, you know, honestly, like you and I know, obesity affects around, what is it, like, 41 percent of the adult population. 9. 1 percent is severely obese. It is an issue for a lot of people. And it gets worse with age, right? The older patients are the most more likely they are to be obese until they hit a certain cutoff. And then the prevalence decreases. So a, it is common B remember obesity has a genetic basis. You know, it's like, I might be born with this. And you're telling me that if I'm born with this and there are available medications, I shouldn't take them? That's kind of, that's a difficult pill to swallow. And then finally obesity has been compared to diabetes. So type two, so obese type two diabetes, we all know is due to insulin resistance. And 90 percent of patients with type two diabetes are, have overweight or obesity. And we're totally fine with covering medications for them again, diabetes medications. Some of them have very high copays. And we were all very excited when there was, insulin$35 for Medicare like that was a big, big deal. And it's crazy that it took this long for it to happen for this like life saving medication. But if we are able to treat diabetes and 90 percent of patients with diabetes are overweight, have overweight or obesity. Why can't we treat overweight and obesity? I think the exciting thing is that, you know, as excited as we are about these GLP one agonists, there are some more amazing medications coming down the pipeline, as I'm sure you know, and what I like to tell my patients is that hopefully that will make the current medications, the ugly little sister. Meaning. They will become uninteresting, not in such high demand and cheaper because really that's what we need. We need to have these medications readily available for patients. The other thing that I think we need to think of keep in mind is that remember that obesity is affected by your race. The number one racial demographic is non Hispanic blacks. The number two is Hispanics. Number three is non Hispanic whites. And so it also becomes an issue of, discrepancy.

Kerry: 11:14

Right. Who's going to get coverage for the medications and things like that.

Asma: 11:17

And then Because these medications are so expensive yet available, they're here, but they're too expensive for you. Patients end up in these, medical spas that are offering compounded semaglutide without any instruction because it becomes a class issue. I have a lot of patients who pay for these medications out of pocket. They can afford it and they love it and some patients who can't really afford it, but it's worth the investment for them. But there are a lot of patients who can't afford it. And so they end up in these like bootleg clinics.

Kerry: 11:48

Well, even still, those are not that cheap either. Right?

Asma: 11:52

totally, those are not that cheap and we're not, you know, we don't have to get into it now, but you and I know about how to make the brand ones, brand name ones last and become cheaper, become more affordable. But yeah, totally. And most patients don't even know they have no idea, they're told, come in, it'll be a hundred dollars a week. Or 200 a week or whatever, when they can get the brand name one for a thousand. So

Kerry: 12:18

very hard to balance that idea of getting that cheaper version of the medicine, but I feel like, I don't know this, but speculation is that the ones that are getting their medication in those other locations aren't always necessarily for diabetes, they're mostly for weight management and it's only getting those who can afford it. And I think it's sad that it has to be like that right now, because I think many people that need it, like you said, are just not going to have access. And that's why you mentioned treating obesity as a disease is very important, right? So to get that coverage to get that not just the employer or anything, but any coverage, even just like saying Medicare, they don't treat that either. So it's important to work with the legislation as well. And I think it's sad that we can, you know, blood pressure, we have the medicine, no problem, no question. Right. And then hopefully people are actually counseling on lifestyle changes that can be done as well with that. But for obesity, it's not recognized like that. So it, it really, I mean, I think that the patients need to advocate for it too, we can do as much as we can do, but it's going to come down to everybody saying so

Asma: 13:32

totally. So I actually, I got a letter in the mail. I don't know if you got it as well, two weeks ago Florida blue. And I'm not saying anything controversial, but they basically told me we don't cover weight management medications, including wegovy, which is, the semaglutide FDA approved medication for weight management. And please inform your patients. That we will not cover wegovy. I saw it and it increased my heart rate because I was like, this is crazy. These are your patients. They're paying good money for you to cover them. And it is my responsibility to tell them that you're not going to cover this medication for a disease that they have. And so what I did is I put it up in my waiting room. I put the letter in my waiting room for all my patients to see because, some patients have have a choice of who their insurance is going to come through, and maybe they shouldn't choose Florida blue if they care about their weight. And that's something that is very important is that we do have a say, we do have control somewhat in what happens to us in terms of medically as well. And it's all about empowering the patient, right? When it comes to weight management, a lot of patients are concerned. They come there and they say, Oh my gosh, doc, you're going to yell at me, and I'm like, who has damaged you? Who has made you think that you're going to come here and I'm going to yell at you? liKe a lot of them, they need that hug to be like, it's all right. It's a lifelong disease. I'm not going to call it a struggle, but there's going to be ups and downs. It's totally okay, and you are in control, guess what? You fell off the wagon for a bit. What are we going to do? You come back. I always tell my patients, if you are doing well, you don't really need to see me. But when you fall off the wagon, that's when you need to see me. When you're ashamed, when you feel ashamed and you're like, oh my gosh, she's going to judge me. That's when you need to see me because I'm not going to judge you. Been there, done that. I was overweight. I know how difficult it is. And B, this is part of the like this is the known path, right? It's never going to be easy. And number three, that's my job, My job is to keep you healthy. And if you are struggling with that, that is when you need to come and see me so that we can talk about all the things that you and I were talking about before we hit the record button. Are you getting your protein? Are you getting your veggies? How are we doing for exercise? How are you doing on processed foods? Are you eating stuff that comes through the window of your car? That's not food. All of my patients know that, you know, anything that comes through the window of your car is not food. And so it is important to just go back to those basics sometimes

Kerry: 16:11

yeah, absolutely. So when you have someone come in what is your method? Do you give them medicine right away? Or how do you evaluate? What do you do?

Asma: 16:20

I have them fill out my forms. I always do a 24 hour food recall because I just find that that's the best way to figure out what's the relationship with food and it gives you a lot of information, right? How's their alcohol intake, soda sugary drinks. Do they binge eat? Do they have night eating syndrome? Because those need to be addressed separately. That's a different issue. I always evaluate their exercise and I always tell them, none is an option. Like, don't be ashamed. Just tell me everything. I want to know the truth so that we can start working on things. And I I always start off by saying, because I'm medical, I'm not surgical, I say weight management is based on four things, a surgeon will tell you five things, but I say four things, especially with these new medications, but it's what we eat, how we move our body, how we behave medications and for some patients, which is the fifth one, which is bariatric surgery, which, of course, has its role. I try my best not to get patients there, but some patients that's what they need. If they need to lose, the weight fast. If they have failed the medical management, that's what that's what they need to do for their for their health. So I spend a lot of time talking about Food. Sometimes I do refer to a nutritionist or dietitian, but most of the time, honestly, I tell patients it's a pretty simple formula. Don't complicate things. You don't, I don't want you to sit and calculate your macros and your micros and how many grams of this and how many milligrams of that, try to keep it simple. The numbers that you need to memorize are 20 grams of protein for every meal for the vast majority of patients. If they're a little heavier, I'll say 30 grams. But 20 grams of protein at meals, veggies at every meal, avoid as much as you can, soda and juice. If you want to have a diet drink, you get one diet drink a day. Definitely, you can skip breakfast, that's fine. Intermittent fasting works great for some people. I never, ever force people to eat but your first meal of the day has to be protein heavy 20 grams, not sweet. low carb, because you and I know when you are eating high protein, low carbs, it's going to suppress your ghrelin levels for the rest of the day. And ghrelin is our hunger hormone. It's like biohacking but it's really just figuring out your body and giving it what it needs. So that's how we start off our eating and then Veggies at every meal, half of your meal is supposed to be veggies, 1/4 or more protein, 1/4 or less carb, and zero carbs is an option the darker your carb the better, and then we talk about minimizing processed foods, the vast majority of us these days, we need to meal prep because we're always go, go, go, go, go, especially professionals, and then especially if you have a family at home, You're going to have to meal prep, or else you're going to be pulling your hair out every night at dinner, trying to feed yourself and the kids something healthy. 150 minutes of moderate intensity exercise is the goal. More is better, but 150 is great. And that's the goal. You don't have to start there, you work your way up. and then finally minimizing processed foods but I go through these gradually. Like I will talk about all of them at the first visit, because some people are overachievers, they want to do all at once, and that's fine. But for the vast majority of patients, I tell them, okay, let's pick the low hanging fruit. Which one do you think is the easiest one for you? Let's pick one or two and work on those for this month. And then next month we'll pick another couple, see what's going on. Rome wasn't built in a day. We're going to do this gradually. In terms of medications. I start medications from the first day for the vast majority of patients. I tell them this is an option and then they choose if they want to be on it or not. But I never withhold it. Old school, the way we used to do it is that we wanted to see the patient, lose X amount of pounds to show that they are committed before we start medications. But really the way that we think about weight management right now is that it's a hormonal disorder. If you have a thyroid disorder or if you have type one diabetes or some, you know, I'm not going to be like, all right, let's see if how you can work on your TSH before I give you a levothyroxine it just doesn't work that way. And I think it's patronizing to tell patients you have to lose X amount of pounds before I give you this medication, because as you and I know the vast majority of patients, by the time they've come to me and you, they've been trying to do this for years and they haven't succeeded. So yeah, I start medications from day one. My go to are the GLP 1 agonists which is like Wegovy. And you and I know, you know, there's the Surmount 3 trial, which was recently published. Terzepatide, which is now called Mounjaro, we think will be approved for weight management in December and will be available. I think maybe it has already been approved. I can't remember, but it will be available in December or January hasn't been approved. Oh, they don't have a name yet for it. Anyways. Oh, it hasn't been publicized. We know.

Kerry: 21:07

date of this recording. Yeah, we haven't found out

Asma: 21:10

not publicized

Kerry: 21:11

lots of rumors.

Asma: 21:12

Yes, exactly. So I think those are the best medications that we have so far, but again, you have to talk to the patients about risks and benefits, you know, medullary thyroid, carcinoma and rodents, pancreatitis in humans, et cetera. GI side effects. They need to know what they're signing up for. And finally, remember how we said obesity is a disease. And diseases need lifelong treatment. And I think that's, you know, a lot of patients are shocked. They're like, I have to take this medication for the rest of my life? Oh my gosh. And it's like, okay, well, if you have high blood pressure or you have a heart disorder or high cholesterol or depression, you have to take a medication for the rest of your life. And it's not such a big deal. Same thing with obesity. It's not such a big deal. Your hormones need to be adjusted and this is how you adjust them. Now, we know that once patients get to goal weight or close to goal weight, we start tapering down the dose to whatever is they need and I've had patients who wanted to come off of it who have successfully come off of medication and kept their weight off for more than six months now. And I think that's important to keep in mind because for some of them, they're just able to adjust their habits, adjust their life with the help of these medications such that once you taper them off of it, they're on cruise control. And once that happens, I tell them, all right, just check in with me, whatever, twice a year. Let's see how things are going. If at any point in time, you feel like you are losing control, give me a call and we'll do something about it.

Kerry: 22:44

Yeah. Obviously, we have a pretty similar approach, I would say. I kind of pull out stress and sleep as their own kind of pillars, but I think you can lump them into other categories like behavior you know, make sure you go to bed on time, but I think those are pretty important comments and then I go a little heavier on the protein. That's all,

Asma: 23:04

How heavy?

Kerry: 23:05

More like 30 at like per meal at minimum, like 90 to 100 a day, sometimes more depending upon the person. But yeah those are important things too, like you mentioned the vegetables and the protein, when you're on those GLP ones. And the other thing is, you know, weight. Training or the exercise part, so you're not just losing the lean muscle mass, right? So I always typically try to counsel that, especially if they're going to, sometimes they're losing weight rather quickly as they increase those medications.

Asma: 23:36

totally. Yeah. So we, they talked about this quite a bit at the endocrine society meeting.

Kerry: 23:41

Mm hmm.

Asma: 23:42

so, and I don't know if you've talked about this before on the podcast, but so weight loss through diet and exercise, weight loss through diet and exercise and ozempic guess who lost more muscle,

Kerry: 23:53

Mm

Asma: 23:54

ozempic arm. And so these medications seem to have a significant effect on muscle because we can't choose, like when you lose weight, you're going to lose fat and muscle so far. But you and I know that there are some medications coming down the pipeline that not only protect muscle, but can actually increase muscle mass. And there's a trial happening right now where they put that medication, which is Bimagromab with semaglutide, which is Wegovy and see what happens. I

Kerry: 24:19

that's exciting.

Asma: 24:20

it's going to be very exciting. It is going to be very, very exciting.

Kerry: 24:24

Yeah.

Asma: 24:24

That's what I got.

Kerry: 24:26

Well, I think the biggest thing that I think you might have wanted to express to people is that the difficulty of the insurance coverage and to advocate for yourself if you want to be or need to be or choose to be or any of these things like on these medications, right? So kind of working with your insurer and representatives or anything or anyone that can help. Make this more of a cause so you could get the treatment that you need,

Asma: 24:52

Totally. And the final thing that I wanted to mention is you and I know about the American Board of Obesity Medicine, but a lot of people don't know about it.

Kerry: 25:00

This is true. Yeah

Asma: 25:01

And so I hear a lot on Facebook, part of the doctors groups that I'm on when I'm out in the community, the People asking about weight management and should I take that shot? What do you think doc? What do you think about that shot? And I tell them go to the ABOM website, American board of obesity medicine. You can actually look for a board certified obesity physician near you, and that's who you need to be calling to ask those questions to, because that's the person who's going to serve you best. Those are the experts in the field, and you don't want anyone touching your body who's not an expert in the field. You go to one of these medical spas, they're not experts. They've got whatever degree yesterday, and this is their one trick. They have one trick, which is the injection. Whereas when you see someone that is board certified in obesity medicine, they have all the tricks. They can solve your problems. So I think that's an important resource to keep in mind.

Kerry: 25:52

Awesome. Yes, the abom. org, I think, right? Yes. Yeah, well, I'll look it up and we'll put it in the show notes. But so how can people find you if they want to work with you or get in touch with you?

Asma: 26:03

Sure. So they can find me at www dot tampa endocrinology institute. com. Our phone number is 8133601214. I'm not very active on social media, even though I know that I should be, everyone says you need to be. But I haven't quite figured I'm old. I haven't quite figured it out yet. But I'll let you know once I do form something there.

Kerry: 26:27

Okay, perfect. Well, thank you so much for being a guest today. We had a lot of fun talking about obesity medicine and everybody, if you are in the Tampa area, South Tampa, right? You can find Dr. Al-zougb And if not, I'm in Clearwater and Palm Harbor, accepting new patients for obesity medicine or primary care. All right. Tune in next week.

Asma: 26:48

Thank you.