Kerry 0:01

Hi, everybody. Welcome back to the Get Healthy Tampa Bay podcast. I'm your host, Dr. Kerry Reller, and today we have Dr. Amanda Kirzner, a double board-certified physician in obesity medicine and anesthesiology, and founder of Accelerated Weight Solutions. She has a unique perspective, having spent many

Introduction to Dr. Amanda Kirzner

Kerry 0:19

years in the complications of untreated obesity in the operating room, which helped shape her passion for treating metabolic disease upstream. So today we're talking about sustainable weight loss, maybe some GLP-1 medications, and what truly works beyond the hype. Welcome to the podcast, Dr. Kirzner.

Amanda 0:36

Thank you so much for having me

Kerry 0:38

Yeah. So why don't you tell us, a little bit about who you are, what you do, how you got started in anesthesiology in the operating room, and then what led you to pivot to obesity medicine?

From Anesthesiology to Obesity Medicine

Amanda 0:48

Okay. So I grew up with an anesthesiologist as a father, so I was always very interested in it. When I was doing my rotations in medical school, when people typically choose what specialty they like, I didn't really love anything, and I decided that I wanted to be in the operating room. I found that exciting, and that I liked doing procedures. So that led me to anesthesiology, and for many years, for whatever reason, I think it happened by chance, but I was put... I was ended up being one of the bariatric anesthesiologists. It just, I think I was assigned there one day, and I got along very well with the surgeons. And when I'm in the operating room, obviously as long as the patient is stable, I'm a big chatterbox, and I'm always asking questions to the surgeons. I was, I would always ask them "So do you put them on an eating plan? Do they have to... What do they have to do to qualify for this bariatric surgery? What happens after? Do you give them guidance? Do you give the guidance? Do you send them to a nutritionist?" And, I would constantly... and then one of them once said to me, "This is, the eating plan I put them on." And I said, "That, I don't think I could stay on that eating plan. How could you possibly put someone who struggles with obesity on an eating plan like that?" He goes, "Most of them don't follow it." And then after some time, one of the bariatric surgeons said, "Do you know that you could become board certified in obesity medicine?" Currently, you do not have to do a fellowship. There, fellowships do exist, but w- I think when I became board certified in 2020, it was CMEs, a conference, and then you took a board exam. And any specialty could do it. Being an anesthesiologist is less common to go and get that additional board certification. I feel like it's many family medicine doctors or internal medicine, some ER. Those are more common, but I felt like it actually fit hand-in-hand very well, because anesthesiology really deals with patients who are morbidly obese, and it really does have an effect on the anesthesia and surgery and what positions we could put them in the operating room, and the techniques that we use every single day. Additionally, I have a master's in public health, and so I do know how big of an issue it is currently. It's actually getting better, but how big of an issue it's been in the United States for so many years.

Kerry 3:28

Yeah I think, they do offer different pathways for certification. I think I got certified at about the same time as you. So I think it's a great addition and definitely unique to be anesthesiology and obesity medicine. And honestly, it makes so much sense if you were, doing, bariatric surgery cases and things like that, that you would, be very curious. I would probably be asking a thousand questions too, so that makes so much sense. That's very cool. So you kinda mentioned that you wanted to treat these problems upstream before patients reach the OR. So what did, what do you mean by that, and how does that work?

Why GLP-1 Medications Are Tools, Not Solutions

Amanda 4:01

So obviously preventative medicine is the wave of the future. It should be the, how we're currently treating patients because it's really hard to reverse things once they happen. It is easier to prevent them. So we have many more tools than we ever did to help patients do that. But these tools, I think, are honestly being misused in the United States. And instead of a tool, I think, for example, the GLP medications, I think people are viewing them as the answer and not a tool. And I think, it's been a couple of years since they've risen in popularity, and I think we're starting to see that. We're running into some issues. And, research is continuing and more and more medications are actually available. I think that education and, with regard to lifestyle in conjunction with these tools that we have are the most important to help prevent certain comorbidities that really do affect patients in the long run and especially when they reach the operating room. Because giving anesthesia for a patient who's morbidly obese is actually very difficult. It's difficult to get the airway in the proper place. It's difficult to decide how much medication to give them because some of the medication, it dissolves in the patient's fat, and then it takes longer to come off, longer to wake them up. Additionally, because of breathing mechanics, when someone is morbidly obese, we can't put them in certain positions because they won't we can't ventilate them as well, which kind of restricts the surgeon because the surgeon operate-- for the surgeon to operate, they, the patient needs to be in an optimal position. So to try to prevent this kind of stuff before they reach the operating room would be ideal both surgery and in general for the patient

Kerry 5:59

I like how you frame it, like the GLP-1s is like a tool. That's exactly what I tell my patients too. It's just one piece of the puzzle for sure. So obviously your experience with, knowing how to position a patient and things like that is very important as well and one great reason of why wanting to prevent it. So that makes sense. I think, somewhere along the way, people used to talk about obesity problems really just willpower. So how do you frame it more as a chronic disease?

Obesity as a Chronic Disease

Amanda 6:27

So I think there are a subset of patients with obesity as a chronic disease who are on these medications, and I think that there are a very large group in the United States that do not have that as a chronic disease that are also on these medications. But with regard to it being a chronic disease, there's not one way only to treat and prevent chronic disease. I think it is, like I said, it's one tool in the toolbox. It starts with lifestyle changes as well in conjunction with medication. And, if we're putting someone on blood pressure medication or heart failure medication, any doctor will suggest that to those patients as well. So we have to look at it like that. And, part of it understanding that it's a chronic disease is that, sometimes the patient is insulin resistant. Sometimes they have done everything they can and they're still just not losing weight. Sometimes that's not the case, and I really... So in my practice, I really look at the patient as an individual, and the thing about these medications is some people do need to be on them for life because like we said, it is a chronic disease. But you have to really look at the patient as an individual because to qualify to be on these medications, it's really a number and a comorbidity. It's a BMI of 27 with a comorbidity. I think they actually will allow some people with 25 or a BMI of 30. But you have to think about and talk to the patient why are they at that BMI of 30. Have they been obese their whole life and struggled? Do they have insulin resistance? Have they dieted? Or did they gain 30 pounds in COVID and they're having trouble losing Did they gain 30 pounds in baby weight and they're having trouble losing it and they haven't been obese in the past? So those patients have a better shot of possibly weaning off the medication because it can be done with strategy and lifestyle change than a patient who truly does have obesity as a chronic disease. And you really have to look at the individual patient to really make a determination, and sometimes there's experimentation that goes along with it as well

Kerry 8:39

Yeah, no I totally agree with what you're saying there with the fact that it's individualized. We don't know the answer. It could be, it c- you would think maybe that they would be able to come off it and maybe they can't, and we don't know. So it's definitely, I think the examples that you gave show the people that could be candidates to come off of it, but like you said, it's, one, it's a tool, and two, it is a chronic disease and we're treating it as such, right? And i- I think that it's very individualized whether they'll be able to come off of it or not, but it's not a no and it's for everybody. Yeah. What kind of biggest-- what are the biggest misconceptions that your patients bring to your practice?

Biggest Misconceptions About GLP-1s

Amanda 9:19

So my private practice is more of a concierge practice, and before I will really start treating the patient, we have a long discussion of their habits and all kinds of different things. I send them for labs, and we talk about an eating plan. Not like-- I give them a guideline, like an eating plan where they will lose weight even if they're not on medication. And it's not like the law. We can make substitutions. If something's really important to them, then we'll find a way to fit it in. But, they have to commit to the lifestyle changes as well before we start treating them. I also do consult for two other online companies, and the patient populations there, I think their expectations are different. They were not educated at that these GLPs are a tool. I think they're looking at them more as the answer, and what's happening is people are moving them up every single month to the highest dose. And what's going on is your body does get used to a GLP. When you have been on it in the past, it doesn't work as well as it did the first time. And they just believe they can go on this medication, they can eat less of the same food, and lose weight for life. And if they have, say, 100 pounds to, to lose, when they go on and they start eating less, they will lose weight. Maybe they'll lose 40 pounds in six months. But they're struggling to lose weight after that, and then they're coming to me saying, "Oh, the medication's not working," instead of a-- taking a step back and examining. All right, we're at the highest dose pretty quickly, and it's not working as well as it was, and I have not made any lifestyle changes. I'm eating a bag-- half a bag of chips every day, which, I did lose weight 'cause I was eating a bag of chips before. But that is not gonna help me with long-term weight loss, even on this medication. And I think that- Yeah there is a big misconception that people have to put in lifestyle effort while on this medication. Like I said, they're using it as the answer and not a tool.

Kerry 11:23

You mean that they don't have to put in

Amanda 11:25

That they don't have to, that they don't have to, yeah

Kerry 11:27

Yeah. I totally agree with that. I think that makes sense. What... Since you have two kind of different patient populations, like how... I don't know. Are they... Do you see a significant difference in what their

Amanda 11:39

difference.

Kerry 11:40

Yeah. Can you explain that?

Why Staying on the Lowest Effective Dose Matters

Amanda 11:42

So for my practice, we stay on the lowest dose for as long as possible. I have patients who have lost all the weight on the lowest dose. Again, because we're incorporating lifestyle changes, we have certain strategies. I could be as little or as involved as patients wants. I do have patients send me their food logs. So as opposed to-- and, I do want my patients, my private patients, to be hungry. I don't want them to not be hungry, and if they go... Because I think people are going on these meds, they are not hungry at all, and they're thinking to themself, "This is how I should be feeling on the, this medication." And it doesn't last. Then they'll go to the next dose, and they'll feel like that temporarily, and that kinda fades fast so they're going to the next dose, and as soon as, you know it, we're at the highest dose and they're not having that feeling. My view is that what I want from these patients is I want them to get hungry, but I want them to be able to be hungry and make good decisions when they're hungry. Because I think it's unrealistic to think that, this... it's probably a lovely feeling to not be hungry at all ever, to not have to think about food. But it's not ever going to last, even if you're on the highest dose of this medication forever. I want my patients to get used to making good decisions, and th- this again is a helpful tool to do so I don't move them up as soon as they're telling me, "Okay, I'm getting hungry during the day." Versus the other population seems to want to do that. It's not as much in my control. I will, consult and give my opinion, but they're not my concierge kind of private patients. And, the, there's this whole talk about food noise and how, it shuts off the food noise. It does, but not forever. Like I said, we're gonna get to the highest dose, and it doesn't shut it off, and you're gonna be thinking about food. But people in life, you will think about food. I will be sitting in the operating room in a six-hour case and all I'm thinking about, of course if my patient's stable, is, "What am I having for lunch? I'm so hungry." So it is a normal part of life. It's how you make decisions with regard to it, I think, that counts.

Kerry 13:51

Yeah, no, I totally agree. I definitely, have a similar practice model in our practice is, lowest effective dose is the best, and I don't say that, unless you're, like, extremely overly hungry and it's a problem, for you, like that's all you're thinking about. But I do want them to get hungry. That's the whole point. It's normal to be hungry at times, right? So I totally agree with you. I think that makes sense, too. And then you can learn other tools and ways to help mitigate the hunger, right? And so tell me, what do you do to help with someone who feels like they're hungry or that maybe that they could use a little more support in that area because their food noise is too much or something?

Hunger, Food Noise, and Long-Term Success

Amanda 14:33

If they're following the plan that I give them, and again, it's a guideline, it's not a plan, it's kinda They really shouldn't be hungry. It's, if you're eating, you need to increase your protein. Fiber is very important. Those two things will really keep you full. I suggest stop eating early in the night. And if they do tell me that, "I'm really struggling at night, I'm starting to binge," then we know it's time to move u- up on the dose. But, an effective dose will be where they're getting hungry but they're making good decisions, they're staying in the plan and, they're able to lose weight like that. And, we also have strategies of how to maintain weight, because I think that's harder than actually losing the weight in the first place. And I've e- I have not had a patient come back and tell me they gained their weight back. Every single one of my patients has kept it off forever, whether or not they've stayed on the medication or not. Of them do choose to, 'cause we experiment when we're weaning them off, and sometimes we will wean them off. And I would say 50% of the patients who come off completely, they come back in a few months and they say, "Listen, with the strategies that we spoke about and I'm incorporating, I have kept the weight off, but it is taking 100% of my effort and capacity, and I'm a busy mom and a lawyer, and you know what? I'd like a little bit of help. I'd like to take the medication once a month or every two or three weeks," or whatever is best for them

Kerry 15:57

Do you, have you used any of the oral medications

Oral GLP-1 Medications vs Injections

Kerry 16:00

yet?

Amanda 16:00

I have. I, my opinion on the oral medication is that it's, whether it be the Zepbound version or the Wegovy version, they're just not as strong of a medication. I think they're, it's good for people to maintain their weight. I think it's good for patients who either can't afford the GLPs because, insurance doesn't cover a lot of them, and lots of insurances that did in the past no longer do, so people can't afford it. Or patients who have a fear of injecting or basically have never injected before. I think it is very difficult for a patient who is used to the injection to pivot and go to the pill. It's just not as strong. It's better than nothing, right? Or, for these patients who are naive to GLP. But I've switched the pa- I've switched patients onto the pill and back off, and in a lot of ways, some of them are telling me the once-weekly injection is easier. Because, for example, the Wegovy pill, you have to take it every single day, you have to be completely fasted. There are issues if they're on other medications of when to time them. So it can be difficult in conjunction with their lifestyle, as opposed to just taking a once-a-week injection

Kerry 17:21

Yeah, and then the other thing you mentioned was, like, the nighttime thing. So I, in the past with Rybelsus, the generic version of... I'm sorry, not the generic, the diabetes version of the Wegovy pill would wear off in more of the evening hours. However, they tell me that the formulation is actually a seven, two-hour thing. But I, from anecdotal evidence from patients they say they struggle still at night when they're just taking that, daily oral medication. So I haven't used it as much because I agree with the way that you said why it's not as good. But I've used it a little bit. So I think that there's a role for it, of course, right? But I d- I think you're right. I think people are gonna really still prefer the injection once they are, used to it and comfortable with it, for sure. But there's all these other medicines down the line and, the Foundeo

Amanda 18:10

coming out with new ones every day

Kerry 18:11

Yeah. And Foundeo I haven't used yet or anything, but I hear it's in our EMR ready to go. That is the GLP version. It's not actually dupbound, but it is just GLP orally. So ha- you, have you... i'm guessing you haven't used it yet 'cause it's not really out yet, but-

Amanda 18:27

It is out. It's Eli Lilly's version. The issue with that, I prescribed it, I haven't really gotten a lot of feedback yet. The issue with that is it interacts with a lot of medications 'cause it works on the same metabolic pathway. So for example statins. So you really have to be on, I think, like 20 milligrams or less of simvastatin to qualify to be on the medication. So there's a lot of drug interactions if patients are on other medications to look out for, it's another option. We have options, and that's good, because if you look back five years ago, we really didn't have options, and that is the beauty of the United States, and we're always advancing, and we are, I wouldn't say experimenting, but we are seeing what works for the population

Kerry 19:17

So who would you think are appropriate candidates for, these medications and who may not be?

Who Should and Shouldn't Use GLP-1s

Amanda 19:22

I'm really opposed, and people take me with a grain of salt and do what they want anyway. I'm really opposed to people who need to lose 10 pounds of vanity weight going on these medications. Every medication has side effect. There's not a medication that doesn't. And I have, again, as an anesthesiologist, I have taken patients to the operating room with complications, mostly GI, a perfed bowel, with complications with these medications. So I think that it's not something that should be taken lightly. I think a patient should be well-educated. I think there need to be strategies to deal with, the patients if they have these side effects, and that's why I also think it's really important not to move them up too quickly. Because again, your body does get used to these side effects over time, and you're less likely to experience them. I also think that there are certain patients who should have in-person care while on these medications as opposed to telehealth. I personally am not comfortable prescribing these medications, and I do telehealth with weight loss. I exclusively do telehealth with weight loss, with heart failure. I think that, patients have fluid shifts when they have heart failure, and I think it's really important for an in-person provider to monitor them in general, but also specifically when they're on these medications

Kerry 20:42

Absolutely. So you you're doing mostly telemedicine, so how do you manage the potential, quote, muscle loss and those kind of things that we think, some people think, are associated with these medicines?

Amanda 20:56

So first of all, I think that the muscle loss comes, everyone can experience muscle loss any time they lose weight, but people who are losing weight rapidly are not getting enough protein. And if you are taking these medications mindfully and you're following a plan and you're making sure to get enough protein, I think you can mitigate these side effects. I think p- patients who are getting this from a random site on the internet and are kinda just doing their thing, they are more likely to suffer from muscle loss. I think that, I don't actually have my patients, if they are not exercisers, I do not have them start exercising at the same time they start this medication. I think it is just too much at once. I think, one ha- new situation at a time. So we really work on their diet to begin with, and eventually we incorporate, light weightlifting and resistance training. And all of the studies have really shown that's really important to, for weight maintenance as opposed to weight loss. I actually think if people are doing crazy cardio, it actually makes them hungrier and can kinda backfire because, it is mostly diet. You can't really exercise your way out of a bad diet. So

Kerry 22:08

Mhm.

Amanda 22:09

those are my thoughts with regard to that. Just, and making sure they're getting adequate calories. Calories, protein, the weightlifting, the resistance training. I think you just have to be really mindful and not lose weight too fast

Sustainable Habits for Busy Professionals and Parents

Kerry 22:25

So you you mentioned habit change a bunch of times and lifestyle changes. So as a mom of five, you're pretty busy, and it sounded like you have some clients who are also pretty busy. So how do help them make, realistic lifestyle changes when they are so swamped every day?

Amanda 22:43

So I think that, again, it's about being mindful, Not just, it's really easy to, just order groceries online and, stuff yourself with junk food. But I actually think there are so many foods a- available with all of the, new products are coming out every single day, and it's actually much, much easier to eat healthfully. There are certain products I recommend to them. I'm affiliated with no companies, but I kinda just tell them what I like to eat and what works for me. They're... I let them have car- I let them have more carbs and stuff like that. I don't really cut anything out from their diet. But we talk about, 'cause I do have a lot of busy working moms, what are portable snacks? What can you bring? What is an easy lunch that you could bring to work so you're not just, trying to grab something from the cafeteria? So I think planning has a lot to do with it, but also in a way that makes it easy for yourself. Because personally, I'm not meal prepping for the week for myself. It's just not happening. But I can buy myself a, Whole Foods has different prepared soups that I like that are low calorie and high protein, and I could just make sure I have that in the house. I can make sure I have apples. I can make sure I have certain single-sized serving foods and just try to make it as easy for myself as possible while, trying to get in the protein and fiber and nutrition that I need

Kerry 24:10

Yeah, awesome. I think, obviously similar, giving them, examples is sometimes very helpful for sure and pointing them in the right direction for sure. Do you have any other specific... Oh, go ahead

Amanda 24:21

Sorry, and I also think not setting people up for failure is really important. Again I am not I'm not gonna meal prep on a Sunday. It's just not gonna happen. I think that if you are a person that does, that's amazing, and you're probably healthier. So I think knowing who you are as a person, if you're someone who is not going to do that, then we have to say, "All right, you're not going to do that. How can we... What can we do? What products can we use? What foods do you like to eat?" 'Cause people are also, not gonna eat foods they don't like, Right? So there's got... There has to be some sort of compromise, but we have to really sit down and kinda plan and prepare to make it as easy as possible to achieve their goals while knowing who they are as people

Kerry 25:04

How do you approach patients or I guess what is something that you wish that patients would ask you more, as being a physician, in this process?

Side Effects, Safety, and Patient Education

Amanda 25:13

Ask for more help. I do have a bunch of patients that will come to me and say, "I already know how to eat. I don't need any, I don't need any suggestions." And then they'll come back to me later and ask or, they'll ask me for tips once they've tried it on their own and they haven't been as successful as they like. But I, I do also wish that people really understood that there, there can be side effects for these meds and when to seek medical attention because they are so widespread and so many people are using them that everyone kinda thinks they're totally benign. And I'm also h- hearing a lot, and I'm not saying this is not true, so many people who are not obese or not overweight are coming to me and saying, "Can you prescribe this to me for inflammation?" Studies have found anti-inflammatory results from this medication. My issue with that is, first of all, at this point in time I'm not comfortable prescribing it to someone who does not have a weight problem. I think that the benefits do not outweigh the risks for them. But I also think that it, it could be taken on a case by case basis. The thing about these studies is they were all done on morbidly obese people and obesity is an inflammatory state so I'm not saying that these medications are not helping inflammation but I'm looking forward to seeing more studies of giving these GLPs to normal weight individuals

Kerry 26:48

Yeah, I know the studies and things aren't there. We did have a, a recent episode where we did discuss them for autoimmune conditions and things like that, and someone was doing a study. So I do think there's a role. I think, if you're being a weight care doctor, I don't... It's out of your, realm to be doing that. I think it's different, maybe in a primary care setting. But you're right it's an individual case basis as well, for sure.

Amanda 27:12

But I look forward to those studies because at this point in time, I'm not 100%. Amazing things have been coming about, about all these GLPs, heart failure and sleep apnea and all of that, but I'm still waiting for the studies. I want an, a

Kerry 27:27

they did them for some of those.

Amanda 27:29

They didn't, I, not for all of them yet. Because then we can, talk about, them to those people, but I don't think we're there yet.

Kerry 27:37

Yeah, we do, a lot of asthma in our office, and they're definitely doing studies on the GLPs in asthma. And asthma's also an inflammatory condition, right? But also can be weight related. It's It'll be interesting. It's it's just exciting. Like you said, there's more research to come, and seeing what other things can be treated with it and, I think it's We just gotta wait and see. Yeah

Amanda 27:57

The other thing I also wish is I don't think people really understand how the medication actually works. Do you find that your patients don't really know how they work?

Kerry 28:07

I do usually explain it, but I don't know what they know coming in. You never know, 'cause it's usually some sort of commercial or social media education, which may be different than what we would provide.

Amanda 28:19

Yeah. More for the consulting I do, I think patients think they're gonna take the medication and just gonna burn all their fat away.

Kerry 28:25

Oh. Oh. I guess I haven't heard that one. Maybe I

Amanda 28:29

Not the case

Kerry 28:30

explained. Yeah, that's funny. Do you have any good wonderful stories, maybe some feel-good stories of any of your patients?

A 120-Pound Weight Loss Success Story

Amanda 28:38

So my best friend lost 120 pounds in the past two years, and she's someone who struggled for her whole life, and she just looks amazing, feels amazing, and she's like my number one success story

Kerry 28:55

Yeah. That's awesome. Yeah. I think the way that it can really turn people's life

Amanda 29:01

It really changed her life, like in every way

Kerry 29:04

Yeah. Simple things from just, being able to go on an airplane and,

Amanda 29:08

rides at Disney World

Kerry 29:10

that kind of stuff too. Yeah, it's amazing. So they are life-changing, so it's wonderful to be able to do that for people. Yeah. So do you have anything else to add? And then I will ask where can people find you if they wanna work with you?

Amanda 29:24

Anything to add, just go into taking these medications with information and understanding how they work and knowing that they're a tool and not the answer to everyone's weight problem. But they are life-changing and can be extremely valuable for patients who need them.

Kerry 29:45

Mhm

Where to Find Dr. Amanda Kirzner

Amanda 29:46

And they can find me at my private concierge practice is Accelerated Weight Solutions. I am licensed in 13 states,

Kerry 29:55

Oh, great

Amanda 29:55

Based out of Florida and New York. But I'm licensed in, let's see if I can remember Maryland, Delaware, New Jersey, Connecticut, New Hampshire, Utah, Wisconsin. Where else? Missouri, Illinois, Pennsylvania. I think I'm missing a few there. But you can find me at www.acceleratedweightsolutions.com

Kerry 30:21

Awesome. Thank you so much for ev- for sharing everything and your wisdom in obesity medicine and anesthesiology. And everybody stay tuned next week for next week's episode, where we're gonna have Dr. Kerzner back to talk about something totally different. So stay tuned.

Amanda 30:36

Thank you. Bye

Kerry 30:37

Bye.