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In this episode, we dive into the complexities of obesity with gastroenterologist Pooja Singhal. Together, we explore the media’s portrayal of new obesity medications, the harmful misconceptions surrounding obesity, and the vital need for a multidisciplinary approach to treatment. Pooja sheds light on the barriers patients face in accessing care, the importance of the Treat and Reduce Obesity Act (TROA), and the broader implications of untreated obesity on individual health and the economy.

Pooja Singhal is a gastroenterologist.

She discusses the KevinMD article, “Understanding obesity beyond lifestyle choices.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome Pooja Singhal. She’s a gastroenterologist, and today’s KevinMD article is “Understanding obesity beyond lifestyle choices.” Pooja, welcome to the show.

Pooja Singhal: Thank you so much, thrilled to be here.

Kevin Pho: Well, you mentioned you’re a gastroenterologist in Oklahoma. Just tell us a little about your story and journey, and then we’ll talk about your article.

Pooja Singhal: Well, I am originally from Oklahoma City. I was born in India, immigrated at age 14, was inspired by my father, who was a physician, to go into medicine. And in undergrad I explored all the science majors and found myself really drawn to medicine as I was shadowing some physicians.

And I’ve had a very fulfilling career so far. I attended medical school in Oklahoma City, and then did my residency, internal medicine, and GI and hepatology fellowship at Georgetown in D.C., and then returned back home to serve my community here in Oklahoma City. I’ve been practicing for about nine years, oh my God, time is flying, after all the training.

And I worked at a hospital for the first eight years of my career in a community setting, and last year I branched off and opened my own independent GI practice. I’m also obesity medicine board certified, and that was inspired by seeing my patients struggling with obesity and non-alcoholic fatty liver disease, which is also called MAFLD now. So that’s my story and my inspiration to go into and incorporate obesity medicine as part of what I treat.

Kevin Pho: So your KevinMD article is “Understanding obesity beyond lifestyle choices.” Now talk about how this article came together, and then talk about the article itself.

Pooja Singhal: Absolutely. So this article came from an effort to educate our country, our citizens, about obesity. There’s such a stigma about obesity. The concept of you are what you eat, it has been so ingrained in our society that anybody who may have an appearance of obesity, who have disease that is obesity, or have fat appearance, there’s automatically the stigma that you’re eating a lot. People do not recognize obesity as a medical disease.

And over the last three decades of research, our understanding now is so much more developed than what it was before. And we definitely know now that it’s a chronic disease, it’s a true medical disease that affects all the organs, or has the potential of affecting a lot of organs, and of course it affects morbidity and mortality.

What people often shy away from, who are suffering from obesity, is talking about it, seeking help. Because for years and years all they have been told is, you know, of course mindful eating and physical exercise, which remain the cornerstone. But now the progress we have made, there are medication options for obesity, there are endoscopic options for obesity like ESG, which is endoscopic sleeve gastroplasty, or intragastric balloon, and then of course there are surgical options.

Often we find in my practice also, people are just embarrassed to talk about obesity or seek help. And we are having obesity increase at such an alarming rate in the United States that I truly feel, and so does the American Gastroenterological Association, that we all have to kind of be treating it, addressing it, and especially gastroenterologists, because we now have the tools to make a difference in this disease.

Kevin Pho: So tell us the types of conversations you would like to see happen in the exam room, and what kind of questions you would like gastroenterologists and other physicians to ask specifically about obesity in the room.

Pooja Singhal: Absolutely. Just like with any other disease, I think it’s important to very gently address obesity. And a lot of times with what I treat, it comes naturally up, because there are disease states that overlap with GI quite a bit, like gastroesophageal reflux disease, commonly known and referred to as heartburn. That has a direct association with obesity or being overweight. So whenever that comes up I address it, and I’ll get into how I address it.

But like I mentioned, elevated liver enzymes, or hepatic steatosis, so fatty cells in the liver. Irritable bowel syndrome also has an overlap with obesity. And of course constipation, diarrhea, what you put in your diet definitely can affect that. So those are all very good opportunities to then address.

So if I see patients who are affected by any of those GI diseases, I do take the time to be like, hey, let’s talk about, this is our treatment plan, but let’s talk about kind of what we can do to address the risk factors and the underlying thing that may also contribute to success. Because we’re setting you up for success, and we don’t want to be dependent lifetime on medications.

And that gives me a good opening to address and assess their mindset, where they are in terms of addressing obesity or not. And just like with any disease, it’s important to make sure the patient is wanting help. And so I always say, hey, do you want to address this, are you wanting to discuss options, because now there has been a lot of revolutionary treatment options and progress made in this field.

And if they say yeah, tell me about it, that’s when I go into talking to them about, hey, these are the options, and have you tried this, or let’s meet where you’re at mentally. My role is to give you education and empower you, and we can discuss more at the next visit while you’ve had some time to kind of think about it. That’s usually most commonly how my conversation goes with my patients.

Kevin Pho: So as you know, over the last couple years we have the GLP-1 medications that are in the news and very commonly prescribed now. So from a gastroenterology standpoint, once you address obesity and establish it to be a chronic disease and you’re moving towards talking towards therapeutic options with that patient, what approach does a gastroenterologist typically take when it comes to obesity?

Pooja Singhal: Absolutely. Well, I think first of all the gastroenterologist has to be comfortable within themselves and their knowledge in terms of prescribing these medications. I do think there’s a role for gastroenterologists to take charge and address and prescribe these medications for the right patient, and if they choose to.

So because one, there is an increased need to address this. Two, a lot of the side effects of these medications, the GLP, actually end up being GI symptoms. So even if the patients are not in your clinic for this, they will end up in your clinic. I often see a lot of patients, they’ve been started on semaglutide or tirzepatide, and then they’re coming with nausea, vomiting, diarrhea, constipation.

So I find that there’s such a big role for gastroenterologists to be on the frontline with this. And because if we are educating them properly, hey, this is what you expect, we are absolutely comfortable prescribing you this medication and this is what you expect, then I think we can definitely help with the obesity epidemic.

I personally think the challenge comes with the monitoring, the demand, because gastroenterology as a specialty field is already so backlogged in terms of, there’s a three to four month wait. How do we work on incorporating that monitoring with obesity? That’s where the real challenge is, because these patients should get three-month follow-up visits, accountability, and assessing the success, assessing the side effects.

Kevin Pho: So I talked to a rheumatologist a few months ago with this exact issue, and a lot of rheumatological diseases that have obesity in context as well, and he turned a lot of his practice into obesity monitoring. So from a gastroenterology standpoint, do you have a subset of patients where you started them on GLP-1s and then it turns out they have to come back and monitor? Is there a subset of your patients that you see for obesity monitoring?

Pooja Singhal: Yes, absolutely, I do. I do have a subset of patients, and I had to actually get help and expand my team, because in order to do justice to those patients I needed to make sure they’re seeing me, they’re seeing my NP or PA, and then they’re seeing me. And I had to properly educate my team appropriately to be able to have a good plan in action.

And there’s a lot of talk nationally. I just did a national talk at our DDW conference about the role of gastroenterologists in obesity treatment, which was first of its kind. And so there’s a lot of conversations that are happening nationally encouraging gastroenterologists to do that. And the more we talk about it, the more the conversations about how do we develop a structure, what tools can we develop that would be kind of a nice blueprint in the field of GI that people adopt.

Kevin Pho: You mentioned earlier about some endoscopic options when it comes to treatment of obesity. So talk more about that.

Pooja Singhal: Absolutely. There are a few. The two most common ones would be endoscopic sleeve gastroplasty, where you go endoscopically and you basically, with a very modified new tool, you can suture the stomach from inside, reducing the surface area to one-third of the stomach. So it kind of mimics the gastric sleeve surgery without going through a full surgical opening up of your abdomen to do that. So it’s relatively a non-invasive procedure as compared to surgery, which gives very good results in terms of weight loss. So that’s one, and that has some great data that has come out within the last five years in its success.

The second one is intragastric balloon, which is, endoscopically you go in, you inflate this balloon, which is medical grade material balloon, with normal saline. You would leave that in for six months, and it’s used as a tool to help adapt and modify behavior, eating of food, and also just giving that restrictive behavior of like early satiety, because there’s a surface area, there’s something heavy there constantly that decreases appetite as well. So it works with that mechanism. And it’s usually used as an interventional tool in people who are overweight, or class one obesity, who are looking for effective ways to lose 30 to 50 pounds within six months.

Kevin Pho: So now we’re seeing more gastroenterologists treat obesity. Are you seeing more referrals from primary care doctors like myself refer specifically to GI to address obesity, whether it’s through a procedural option or through medication options?

Pooja Singhal: That’s a great question. I have to say, I started getting more referrals once I reached out to my colleagues in the community and informed that, hey, I’m doing this. And so once I reached out and they knew about it, that’s when I started getting more referrals. It’s still very few people are doing this in Oklahoma community, so there’s still a lot of awareness that’s needed. But yeah, as soon as I reached out, I do get those referrals, absolutely.

Kevin Pho: And in terms of the endoscopic options, are we looking primarily at urban academic medical centers, or are they available typically at community settings?

Pooja Singhal: So that’s a fantastic question. So that’s been a long term debate. So there are right now academic centers for sure, and not in every state yet. But academic center is probably, if I was a patient seeking this out, I would contact the urban academic center.

But there are places that have a couple of private centers that I know, there’s one in North Carolina, there’s one in Seattle, that there is a gastroenterologist and their team that’s just dedicated to endoscopic bariatric intervention, and they have a whole team and setup like that. But it’s not fully widely available yet. But we are hoping the next decade it’s going to be something that a lot more gastroenterologists are going to be trained at, and we will be able to make it more accessible.

Kevin Pho: In your article you also talk about the Treat and Reduce Obesity Act that aims to address disparities in access to obesity treatment. So talk more about that.

Pooja Singhal: Yes, I’m so glad that you brought that up. So Treat and Reduce Obesity Act has been a bill that has kind of advocated for expansion of Medicare coverage, expansion of intensive behavioral therapy, and it really advocates to get more coverage for obesity treatment.

So as we just discussed, it’s a very complex disease. There is multiple things at play, of course behaviors, of course eating component, genetic predisposition. So we really need a multi-disciplinary approach, and we have not had traditionally any coverage in terms of behavioral therapy. Even pharmaceutical coverage is very limited. So this Treat and Reduce Obesity Act is all about advocacy for insurance companies, Medicare specifically, to expand coverage for those services.

Kevin Pho: We’re talking to Pooja Singhal. She’s a gastroenterologist, and today’s KevinMD article is “Understanding obesity beyond lifestyle choices.” Pooja, we’re going to end with some of your take-home messages that you want to leave with the KevinMD audience.

Pooja Singhal: Well, thank you for that opportunity. I think my take-home message for my peers, my professional audience, your professional audience, would be the lesson I have learned within the last few years is just knowing our self-worth and our value, and just being mindful, living in the present. So knowing that has helped me stay in a very positive mindset and be happy.

And for patient audience, always self-advocating. If there’s something wrong, or if you have questions, seek answers, really ask questions if you don’t understand anything. And if you feel like you’re not getting your answers, always seek out a second opinion, because it’s really important to have that patient and physician positive relationship for long-term good care.

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