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Join us for a conversation with Zachary Fellows, a rheumatologist who spent nearly four years in private practice navigating the complex intersection of obesity and rheumatic diseases. Zachary shares his journey from giving vague weight loss advice to becoming well-versed in obesity medicine, ultimately transforming his practice and patient outcomes. We’ll explore how obesity exacerbates conditions like osteoarthritis and fibromyalgia, the challenges primary care physicians face in addressing weight loss, and the critical role specialists can play in supporting these efforts. Zachary discusses the importance of multidisciplinary approaches, the impact of societal factors on obesity, and his advocacy for better medical education on weight management.

Zachary Fellows is a rheumatologist.

He discusses the KevinMD article, “Addressing obesity: Is there a role for us as specialists?”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Zachary Fellows. He’s a rheumatologist. Today’s KevinMD article is “Addressing obesity: Is there a role for us as specialists?” Zachary, welcome to the show.

Zachary Fellows: Thanks for having me, Kevin, really appreciate it.

Kevin Pho: So let’s start by briefly sharing your story and journey.

Zachary Fellows: So, gosh, I graduated from Ross University about ten years ago from med school, and then I went to San Diego, Scripps Clinic, for residency, internal medicine. Then interestingly met my wife there, dragged her off to the University of Wisconsin for my rheumatology training, and she’d never left the warm climate ever, and so this was a shock to the system. Great time, great training.

And at the end of the day she wanted to come back to California and be closer to home, so I joined a private practice in the Bay Area and was there for almost four years. And towards the end of that we found there were some family things that were starting to get a little bit tricky, and so we had to move back to San Diego, and so we made that move earlier this year.

But the trick was, I’d been in the systems before, I’d been in academia, and I flourished in private practice, and so I wanted to continue that. So when we came down here I started my own. But there’s a spin. So I’m practicing rheumatology as the primary focus, but with an adjunct of obesity medicine.

So towards the end of, I would say probably halfway through or towards three years in my time in private practice in the Bay Area, you would start to see folks with rheumatologic conditions, and I’ll just say osteoarthritis of the hip and knee is probably the most common example, where obesity is pushing the gas pedal, so to say.

And we do what we can do. You know, we do our Tylenol and NSAIDs and injections, and you’re trying to get these folks better, and at the end of the day you’re left with surgery. And honestly with obesity, at a certain point you can’t have that surgery anyway.

And so you’d have this conversation, you would ask, have you talked to your primary doctor about weight loss, have you had this conversation with anyone? And so often the answer would just be no, blank stare. Or maybe they talked to their primary and they just kind of unsatisfactory result. The issue is these things weren’t being addressed.

And so I started looking into this and thinking, well, as I’m going to be transitioning to my own private practice, wouldn’t it be great if I added this along as an adjunct of service? What if I add this to my practice to add value to my patients?

And I have, and it’s been a huge hit. Patients have been over the moon about it. To clarify, I’m not operating like a weight loss clinic per se, that’s not what I advertise or market. I am rheumatology first, but there’s obesity medicine on my door. And so either patients themselves will say like, hey, saw this on your door, what are you doing? Or just naturally as our relationship flows, I may bring it up to the patient, say, hey, by the way, have you had that conversation about weight? Now I have a much better answer than I did, you know, two, three years ago. I can actually do things about it. So it’s really good experience for my patients and really helped my practice flourish.

Kevin Pho: Give us a story and an example of how weight loss really moved the needle in one of your patients specifically, to their rheumatologic condition.

Zachary Fellows: Oh my gosh, I have this rock star of a guy. Psoriatic arthritis, and he’s honestly a young guy, maybe in his 40s. That’s young nowadays, right? Younger guy in his 40s, but struggling with obesity for a long time, and it’s limiting his movement, then he’s got the psoriatic arthritis on top. And those two often go together anyway, right?

So we got him on the right inflammatory treatment, chose the biologic that suited him better than what he was on. He got some pain relief. But osteoarthritis, all this degenerative business had built up courtesy of the obesity.

So we started splitting our visits, and we would do like a check-in for the biologic, and then a few weeks later we’d come back, we’d really just be specifically talking about weight. And so over the course of about six months with him, he shed about 10 percent of his body weight. And every time he came back he was a little bit closer to that goal, and just the smile on his face was bigger and bigger and bigger. He’s like, Doc, I’m moving better, I’m swimming laps in the pool now, I was never doing that before.

And just, it’s that joy. And I think all of us went into medicine to get some of that joy. It was an incredible story. He’s my poster child, but there’s been a few others like that, maybe just not as phenomenal.

Kevin Pho: So let’s talk about your KevinMD article, “Addressing obesity: Is there a role for us as specialists?” For those that didn’t get a chance to read it, tell us what it’s about.

Zachary Fellows: Yeah, so I’m in some social media groups for physicians and rheumatologists as well, and so folks had been asking, I think especially in these last few years of the GLP-1 explosion, folks are asking like, is anyone doing this, is anyone prescribing these medicines, is anyone practicing obesity medicine or weight loss in your, whether it’s rheumatology practice or otherwise? And not many people are piping up, and some are like, yeah, a little here, a little there.

So the point of the article was to share my experience with it, and how it really was an organic need that I saw in my patients, how I came across the CME, and how I integrated this into my practice.

And the point I really wanted to make is that we all don’t need to go and get obesity medicine CME and open up a weight loss clinic. There’s a huge demand, right, that’s not what I’m suggesting at all. We’re too busy, we have too much stuff going on. But is there a role for us to be a little bit more well-rounded with that?

Let me give an example here. Obesity is not like a primary care exclusive issue, right? I mean, it’s a cardiology issue, it’s a pulmonary issue, it’s an orthopedic issue. And so when we’re seeing these patients who have obesity that’s maybe feeding another comorbidity, it doesn’t hurt to have a little bit more behind you, so if someone asks what can I do, or how am I approaching this, having a better answer than, like I said, I did. I think that’s the key point I’m trying to make.

Kevin Pho: So how much extra training and education did you receive before you felt comfortable to put that obesity medicine shingle by your name in addition to rheumatology?

Zachary Fellows: That’s a good question. So it’s not that much, actually. So let me make that point.

We all learn about the same nutritional content in med school, right? I mean, we had to go and memorize like the Krebs cycle, the nitty-gritty of fatty acid metabolism and all these terrible things. But I know at least for my school, my program, we certainly got through that, but I remember like less than one hour on ghrelin and these other hormones, and less than that, how do we use these things, what are the practical applications of this in terms of treating patients? I don’t think I had any of that.

So if you go through the CME, I went through the Obesity Medicine Association, and there’s several CME providers, there’s courses that are offered every year, like Columbia has one and I think Harvard has one too. But point is, yeah, they round out some of those nitty-gritty molecular things, just refresh you more than anything else, but they add this practical treatment content that none of us really got in school.

But it’s actually not that much. I mean, most folks who practice, we’ll say practice weight loss or obesity medicine, they’re not board of obesity medicine certified. You don’t need to do that, you don’t need a year of fellowship, there’s not that much extra content. And so the CME was about 30 some hours or so, which was probably in excess.

But you learn these nitty-gritty things about how to apply. I mean, different targets of protein intake that people should be going after, different targets for fiber, how to use the medications, what do we do when the medications don’t work. So it turned out not to be all that much, but for someone like me who just had that hour of nutrition in med school, and internal medicine residency with primary care clinic and endocrine rotations, I was still clueless, like how to apply that towards patients. And so it turned out not to be very much content that paid off in a big way.

Kevin Pho: So tell me your approach. If someone comes to you specifically for obesity, or if you wanted to treat obesity in the context of their rheumatologic condition, what’s your approach? How would you start?

Zachary Fellows: I’ll tell you mine. The first point is that we’re all super busy, right, and some of our clinics are packed full. Right now my clinic is still growing, so I can make time for these extra visits. Usually it requires an extra visit.

And so if I have someone I’m seeing for a rheumatology condition already, and then weight loss interest is expressed, I’ll say let’s set a follow-up appointment and that’s all we’re going to talk about. Come on in, we’re going to go through this thing.

And then we talk about their background, we talk about their weight history, has it been up, down, rise fast, lose slow, what things have been tried, what diets have been tried. And then you try to understand how much they understand about nutrition and diet and so forth. I mean, there’s so much information out there on the internet, YouTube, TikTok, left, right, and center, and everyone comes in with a different level of understanding. And I’ll actually probably say misinformation too, right?

So you get that, you assess, you understand where they are, and then you work on building that education, you deconstruct the misinformation. You know, keto diet isn’t for everyone, for instance.

And then it’s about having a plan. What are we going to do for diet, how are we going to track calories, do you know how to track calories, what are you going to do for activity, exercise? Let’s spell that out exactly what you’re going to do and let’s work on that.

And then medications we enter very early as well, just as an adjunct to speed things along, and that’s even easier nowadays than it has been, just courtesy again of the GLP-1s.

But you have that visit, and then usually have frequent follow-ups. You’re seeing folks every two, three weeks, check in, what are you doing, what are the calories, and you kind of keep on going. And you spread out those visits as you start seeing some success. Normally you’ll see folks for, I don’t know, three to four, five months maybe at that fashion, and then you spread it out every three to six months, something of that sort, to maintain.

This is something you’re doing in addition to their usual care too, right? And so the way I designed it is that they’re still rheumatology patients, that’s their primary focus, and so these visits are either extra on the side, or occasionally if we don’t have much to talk about rheumatology wise, we squeeze it into that visit. But not possible if you’ve got a short appointment necessarily, not possible if your schedule’s already, you know, like 24 folks a day. Sure, it’s going to be hard to squeeze these folks in.

Kevin Pho: So you mentioned GLP-1s several times. Obviously everyone is talking about that, very popular on social media, in the news. So how do they fit in your weight loss approach?

Zachary Fellows: GLP-1s are great, and the GLP and GIP as well, Zepbound. But the struggle with those is accessibility right now. They’re generally recommended first line now, if we’re looking at medications. It’s not the only thing you do by any means, it’s something you add as an adjunct, but we want to be using these as early as possible because they’re just so effective.

It’s not that the other medications that we, I don’t want to say used to use, we still use these, but like phentermine and bupropion-naltrexone, those things, it’s not that those don’t work. Those drugs, maybe you’ll get about 10 percent weight loss in a year. I mean, even with Wegovy you’re talking 15 percent, Zepbound is closer to 20 percent. And so anyway, you want to get these drugs on board.

I’ve got, let me just ballpark, maybe about 15 percent of my prescriptions for GLP-1s are actually covered and get filled at a reasonable price. I’ve got a few folks that choose to pay out of pocket, which is just, the price is crazy high. But insurers are just boarding up the windows, they’re locking the doors, they’re turning their phones off, they’re just not covering these at all. It’s been really difficult to get those covered. So I’d like to use these more, all of us would like to be using these more than we are, but things are going to have to change. We just don’t know when that’s going to be.

Kevin Pho: Sure. So with these medications, like in primary care, I talk to other physicians, then you have to reframe obesity more like a chronic disease, right? Because if you stop these GLP-1s the weight tends to come back. When you introduce that possibility to patients, how do patients normally respond?

Zachary Fellows: That’s also a great question. They don’t care. They say, OK, OK.

I mean, folks, most of these who go to their doctor and are asking for help with weight loss, this isn’t like obesity snuck up and showed up overnight. I mean, often they’ve been struggling for years, years or decades even. And maybe they’ve gone through and tried these other medicines, we’ve tried phentermine, we’ve tried the other ones, nothing worked, I couldn’t tolerate it or I couldn’t take it.

So, this works, if it works and I’m going to lose weight, give it to me, I’ll do it, it’s fine, let’s go. So I haven’t had any patients really give kickback on that. That is a real concern, that rebound weight, but if it’s been something they’ve struggled with for so long and caused so much harm, there’s a lot worse things than having to take a shot once a week.

And there are options on the horizon, these are still in phase 2 trials, where the dosing is less frequent. And then of course there’s oral. There’s already an oral GLP-1 on the market, just not approved for weight loss, for diabetes. But there’s GLP-1s that are in the works that are oral and intended for weight loss, that’ll make that even easier for folks to swallow. I mean, no pun intended.

Kevin Pho: Are you worried about any potential long-term side effects that we may not be aware of yet?

Zachary Fellows: It’s timely you say that. My best friend’s a hospitalist and he gives me grief all the time, and he’s like, you know, at some point the shoe’s going to drop here and there’s going to be something, this is going to be a fen-phen moment.

You know, the drugs have been around for 20 years in research and they’ve been in the market for, don’t quote me, ten plus at least. But I mean, even liraglutide, Victoza, that just went generic, that just went generic last month, or this month, I don’t know. But point is, they’ve been in the market for a long time and we know what the risks are.

And there was an article that came out this morning or yesterday suggesting non-arteritic ischemic optic neuropathy was found in folks at a slightly higher risk. But it was a study, they didn’t control for BMI or A1C, because I think diabetics were involved, and so you’ve got to take that kind of data with a grain of salt.

But so far the data has shaken out really well over this last 20 years. And anything that we do, coming back to just generally speaking instead of GLP-1s, anything we do is benefit and risk, right? We’re not going to engage in something if the risk is greater than the benefit, but the benefit from these, it just landslides over that risk as we currently understand. That’s not to say we go in blind and recklessly, but the data we know now is supportive.

Kevin Pho: So do you get any pushback from obesity medicine specialists, primary care doctors, asking, you know, why is a rheumatologist doing weight loss? Any pushback at all?

Zachary Fellows: You’re just killing it with all good questions. Yeah, no, this is something I’ve been concerned about too.

I’m really careful about how I approach things, because again, obesity medicine, or the practice of weight loss I suppose, it’s not necessarily exclusive to primary care, but it really is something that primary care docs tend to address. And so if I ever engage in weight loss with any patient, I’m having them check with their primary first, or I am talking to that primary first. We have to be careful not to step on toes.

I mean, like if you send someone for a hernia repair to a general surgeon and the general surgeon starts saying, hey, your blood pressure is high, I’m going to start amlodipine, you’re probably not going to send that guy hernias anymore. You know, there’s lines that can be crossed, so you’ve got to be careful.

So I would urge that again, any specialist that goes this direction, I hope more do of course, that’s the kind of thing, I have to be careful not to step on others’ toes, cross those lines.

Kevin Pho: So flip side to that question, have you inspired any other specialists to incorporate more obesity medicine into their practices?

Zachary Fellows: The questions come up more and more and more. So I shared my experience again in a social media group just for rheumatologists specifically. There was interest in others asking how we go about doing this.

I’m seeing more and more the, it’s called the diplomate of the American Board of Obesity Medicine, the board certification, seeing more and more of those around. We have a conference for private practice rheumatologists, going on its second year, coming this October, and we’re having a talk about that very thing, is how do we integrate obesity into the practice, because there has been such interest in it.

So there’s more and more. I think the GLP-1s really opened the eyes of a lot of folks. I mean, it created options where maybe we didn’t have that many options previously, and I think it’s encouraging more to say, hey, maybe I should get to be a little bit more familiar with this.

Kevin Pho: We’re talking to Zachary Fellows. He’s a rheumatologist. Today’s KevinMD article is “Addressing obesity: Is there a role for us as specialists?” Zachary, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Zachary Fellows: Yeah, so at the end of the day, the article, and I’m not telling you otherwise, I’m not saying hey, we should all go and open up a weight loss clinic. No, no, no.

But a lot of those CME dollars that most of us get annually, if you’re looking for a place to spend them, my eyes were just blown open by the value of that obesity training that I added on. And again, I’m not operating a weight loss clinic at all, but really just having that extra information has been incredible.

And so take-home message would be, if you’re looking for a place to spend that, and you’re involved in anything downstream from obesity, which is again quite a few different niche specialties, it’s a worthwhile spend to look at that CME.

Kevin Pho: Zachary, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Zachary Fellows: Thanks for having me, Kevin. Great.