**Jim Hill:** Welcome to Weight Loss And, where we delve into the world of weight loss. I'm Jim Hill.

**Holly Wyatt:** And I'm Holly Wyatt. We're both dedicated to helping you lose weight, keep it off, and live your best life while you're doing it.

**Jim Hill**: Indeed, we now realize successful weight loss combines the science and art of medicine, knowing what to do and why you will do it.

**Holly Wyatt:** Yes, the “And” allows us to talk about all the other stuff that makes your journey so much bigger, better, and exciting.

**Jim Hill:** Ready for the “And” factor?

**Holly Wyatt:** Let's dive in.

**Jim Hill:** Here we go. Welcome to another episode of Weight Loss And. Holly, this morning, we're going to take an interesting topic. We're going to discuss how to talk to your doctor about your weight. When we thought of this topic, there was only one person who came to mind for us to talk about that.

**Holly Wyatt:** Very true.

**Jim Hill:** Yeah. Our guest today is Doctor Dan Bessesen. Dan is a former colleague of ours. Dan and I have been together for almost 30 years, working together. Dan is a professor of medicine at the University of Colorado, Anschutz Medical Campus. He's the director of the Anschutz Health and Wellness Center. He's the Chief of Endocrinology at Denver Health. He's an endocrinologist who really does talk with docs, and talk with people about their weight.

He's a former president of the Obesity Association. Dan is a gifted lecturer. This guy is the best I've ever heard at talking to physicians about how to deal with their patients but we didn't ask him here to talk about that. We're going to flip it around and ask him to talk about how people who are managing their weight can talk to their physician. Dan, welcome to Weight Loss And.

**Holly Wyatt:** Dan has had a huge impact on my career. Dan is really the reason I am an endocrinologist today. I met Dan when I was doing my internal medicine residency and I was not going to go into endocrine. I was not going to study weight and obesity and I was going into, infectious disease. I met Dan and he really painted this picture of how I could study weight and obesity before it was cool and endocrinologists did that and I changed my whole career path because of Dan. And I always say Dan really taught me everything I know about endocrinology, the real basics of it. He could teach anything but more importantly, Dan taught me how to talk to my patients about their weight. I always say he's really good at combining the science and the art of medicine. And it's Hill to this day, there's frequently when I'm talking to somebody or I'm thinking about something that I think about what would Dan do or really more importantly what would Dan say at this point. So this is the perfect topic for Dan and I had to say, Dan, you used to ask me the tough questions when I was a fellow. So today, be warned, we're going to ask you the tough questions.

**Dan Bessesen:** Well, you guys are just so kind. I'm left a bit speechless and it's such a joy to see both of you. I don't get to see you like I used to. And, Holly, just to see kinda what you've done with your career and your life, it's so impressive. And, Jim, you made such an impact on my career at a number of key points. And so it's a real pleasure to get to talk to you both.

**Holly Wyatt:** So to get us going, I think things are really at a kind of a pivotal time. Things are really evolving when it comes to obesity medicine. It's now, Holly, more than ever a two-way street. Patients are now, I think, wanting to bring up their weight with their healthcare providers. I know we spent so many years, Dan, trying to figure out how to bring up weight with our patients in a way that is helpful. Now I think that it's a two-way street and these new weight loss medications are really changing that discussion. Many people now see obesity as a medical disease and it can be evaluated and treated like other diseases and they want medical help, which brings up this question, how do people talk to their doctors about weight loss?

**Jim Hill:** Let me put this one to you, Dan, that oftentimes in the past, a lot of people managing their weight have not turned to their physician as their first choice for help. They've gone to a dietitian, a trainer, the Internet, different diets. If people listening are really interested in managing their weight, should they bring their physician into the conversation?

**Dan Bessesen:** Yeah. I think, a health care provider, whether it's an advanced practice provider or a physician, is a critical piece, of your, weight loss journey. I think it's important for you to have a conversation with your doctor about your weight. As I was thinking about this, though, I thought there were a lot of flavors of conversations. There's not one right conversation just like there's no one right way to lose weight. And so I thought before we sort of say how do we bring it up, I think it's useful to paint a picture of what a good conversation looks like with a doctor. What are the key elements that make something successful? And I think the starting point is Holly says things have changed, and they have. But the more they change, the more they stay the same.

Holly knows this because she sees patients. That relationship between a patient, a person who's coming to see a doctor, and the doctor, it's just a really wonderful thing or it can be a really wonderful thing. It's a personal relationship, and the conversation sounds like any good conversation. You have 2 people who enter the conversation with an open mind, who are willing to listen to each other, who are aware of at least and hopefully express their own preconceived notions and biases on both sides. And they're to share information with one goal, as a doctor, my goal is to help the person in front of me make progress in their work towards some feeling or action around their weight. I don't have all the answers, but I think a good conversation starts with that as a framework for what are we shooting for.

**Jim Hill:** Wow. So many questions, Dan. In the past, a lot of overweight people have avoided going to their physician. How has that changed? And maybe a little bit about why they did that and how you think that's going to be different.

**Dan Bessesen:** I was thinking about this topic today, and I think weight is an uncomfortable topic not just for patients, but for doctors too. I relate it to almost like those patients who have some sexual issues. Sexual conversations are difficult for doctors and patients. They people have some, discomfort, sometimes shame. The doctor doesn't know what the right words to use are, and weight can be like that. I think what's happened now, I see, is people feel empowered, and sometimes they come in, with an agenda. They say this is what I want to happen here.

And remember what I started with. I think, how does this work? The doctor shouldn't have an agenda. The patient shouldn't have an agenda. What we want to have is a meaningful, useful conversation where information is exchanged. So I think the person who is, afraid to bring it up, that's not going help you. I think get over it. Bring it up. You're an empowered consumer.

On the other hand, if you have so much of an agenda that all you're looking for is a prescription from the doctor, that's not going to be as useful to you as if you really have a conversation and find out what the doctor knows, find out how they can help you, and so keep an open mind.

**Holly Wyatt:** So, Dan, I remember you used to give me prompts to help me kind of think about what to say. One of the things we taught actually after many years for physicians who are uncomfortable talking about weight is to ask permission, to simply go in and say, would it be okay if we talked about your weight today or some variation of that question? And I think at first, I didn't like that. I think I even pushed back a little bit and said, well, I don't ask permission to talk about blood pressure or something else. But as I've grown in this, I realized that is sometimes a good way to just get the subject to bring it up. A question for people who are nervous about it. It is uncomfortable. Is there some kind of equivalent question to get the ball going that perhaps they could ask their health care provider just to get it going? Because some people say, I don't know what to say. If they don't bring it up, I'm not sure how to get the subject going.

**Dan Bessesen**: If you're going to go buy a car and you wanted an electric car, you'd go in and you just say, I'm here. I'm looking for an electric car. I got $40,000. I don't think I can get very much. Can you help me? That's what you do, and I think that's what you do. If you're worried about your weight, if you think your weight is an issue for your health or your life and you want help with that, maybe you don't know what your doc’s going to give you, but I think you should feel empowered to go in and say, I've been worried about my weight for these reasons. I've had a few thoughts about it, but I value your opinion. You've known me for a long time. You know my health. Would it be okay if we talked about my weight for a little bit? Could we devote some time to that? And I think your doctor wants to help you, and they want to be efficient. And so in some ways, you've taken the pressure off the doc. The doc may not know how to bring it up. They may be worried about your weight. So to have you raise the flag and say, this is a weight-focused visit. Can we please talk about this? Wow. It really just opens doors.

**Holly Wyatt:** So what about that? Is it something that should be handled in, like, just a routine visit? Do you think it's good to ask for a special visit for that? What are your thoughts on that?

**Dan Bessesen**: Holly, you remember Lee Perot. Lee has this NIH grant with this program called Pathway. I think this is a great idea. The idea is that at the front desk of the primary care office, this isn't a subspecialist, primary care office, there's a little sign that says if you want to have a weight-focused visit with your doctor, sign up here. And what happens then is the office sends out a list of questions. What are your weight goals? What have you tried in the past? What do you have questions about? This kind of stuff. And so then the doc comes into the room not only knowing that this is a weight-focused visit.

We're not going to talk about your diabetes today or your arthritis. We're going to talk about your weight, and the system is behind that. They say, yeah. We'll code and bill and support that kind of visit. It's going to last this long. And so the doc knows that I have an activated patient who already wants to do something. Oh my gosh. I spent half of my visit trying to figure out what’s going on here, and what this person want. So I think it's a great idea and one that you can do yourself.

If you're a person, you can say, I would like a weight-focused visit, and let me give you some information ahead of time whether you have one of these electronic records where you can send some stuff. Don't overburden the doc. They only have so much time. So be aware of the constraints that your doctor's under, but make it as efficient as possible.

**Jim Hill:** I love that idea. I wish more places would do that, Dan.

**Holly Wyatt:** But I think that that term I like a weight-focused visit. Sometimes they don't even know how to word that, a weight-focused visit because that allows you to go in there, they know what the topic's going to be and you can talk really about anything versus what I think happens a lot of times is they go through the whole visit and as the doctor's leaving, they got their hand on the doorknob, they're walking out then suddenly the topic of weight comes up, and that's kind of hard at that moment to kind of really do it justice, I think.

**Dan Bessesen**: Holly, I think for your listeners, I think they have to be aware that the doc has their own agenda. Just like you talk to your spouse that everybody's got an agenda, often the doc will start a visit by saying something like, so do you have some concerns you want addressed today? Or how are you feeling today? And right at that from the get-go, it's fine for you to say, I know you got stuff to do. We have to refill my prescription stuff, but I hope we can save some time to talk about my weight today because that's important to me.

**Holly Wyatt**: Yes. That's the perfect time to kind of set the stage and the doctor may say we're going to need to set up a separate visit for that, but you've got the ball going. So I like that too. So I wrote this question down because like I said, Dan, I'm writing all the difficult questions down that I want to know the answer to. Whose responsibility is it to bring up weight? I mean, if it's a disease, we do think of obesity as a disease now. Is it the responsibility of the doctor to bring it up or is it the responsibility of the patient where what do you think about that? I feel a responsibility if someone's blood pressure is high. Feel like it's my responsibility to bring that up. I'm not going to let them walk out of the office with a blood pressure that's super high.

**Dan Bessesen:** Yes. I think, there's no simple answer to that question. I think it's a relationship between a patient and their doctor. They both have responsibilities to bring up topics that they think are important and that they think they're ready to do something about. And I think the reason we brought up blood pressure for so long was we had great medicines. We had benchmarks. We knew how to treat it, and we understood it. Some of the challenges for a lot of primary care dogs with weight is, yeah, well, nothing's covered, and people aren't motivated for this, and diet doesn't work. And so they're frustrated. It's not that they don't think it's important. It's just that they don't see something that's actionable. So who's responsible to bring it up? It's a joint thing. It's the doctor's responsibility to prioritize your health problems, and what they want to address during the visit. It's your job to bring up what's important to you. And then the 2 of you negotiate, what are we going to prioritize and how are we going to do it?

**Jim Hill**: Okay, Dan. I want to switch gears just a bit and talk about the gorilla in the room, the new weight loss medications. GLP 1 has become a conversation at the dinner table. In my career, which lasted several decades, this is one of the biggest disruptors, and I use that in a positive sense. I think for the last few decades, we've made small progress in treating obesity. These drugs are really a powerful new tool. How is this changing the relationship between patients and physicians when it comes to weight?

**Dan Bessesen**: It's such an important question and one that I think your listeners are interested in knowing an answer to. I guess, again, I started the way I did very intentionally. The more things change, the more they stay the same, which is patients and doctors are each trying to serve each other and get something from each other. And the challenge right now is the ground is shifting, as you say. I imagine the world in 10 or 15 years, and I think these medications, and you guys know the ones that are coming along. I mean, these semaglutide's great. Tirzepatide's even more potent.

Semaglutide, kigronetide, even more potent. Ritatretide, even more potent. These medications all cost more than bariatric surgery does for long-term therapy, and there's just no way everybody can be treated with these. Those small number of facts that I just related there just describe what a disruptive time this is, a terrific time. People who Holly worried for so long there's nothing I can do, there will be something that people can do about their weight in the future. But that's not the world we live in right now. Right now, we don't know who's the best person to prescribe which medicine to. The insurance coverage and accessibility of medicines is a huge problem.

But that's kind of a world that doctors and patients have been in forever. We deal with uncertainty. We deal with limitations, and your doctor is your partner in this if the doctor wants to do that and is a good doctor. I found myself thinking, well, there are a lot of people you could go to. Should I tell your listeners, well, go see an obesity medicine specialist or go online and see somebody there, Or what if your doctor, doesn't know that much about it? Maybe dump your doctor, and find another doctor. These are all possibilities, and we can talk about some of those if you want to. But I think you're in the office today with your doctor.

Make that a useful conversation for both of you. Your doctor has some information. Maybe you're going to find it useful, maybe you won't. But have an open conversation, and find out what the doctor knows about it. Some doctors are interested and knowledgeable in prescribing new medicines. I'll get back to your question. Sorry. I went on a diversion there. But if your doctor knows about these medicines and can talk to you about them knowledgeably, that's great. If they don't, you need to get past that to somebody who can answer your questions. But don't forget that your doctor may know you better than other doctors do. Your doctor, he or she knows your health problems. They know your health history. They know what motivates you and what your goals are. And that is a huge asset. That person's part of your care team that can help you navigate the other pieces of it.

**Jim Hill**: As you know Dan, Holly and I are working a lot in lifestyle and we feel like lifestyle's important. And it's interesting with the new meds coming out, some behaviorists actually oppose them as, oh my gosh, it's the easy way out. We actually see these as wonderful tools but not stand-alone tools. I just don't think that medication alone is the only solution. We talk a lot about what is success in weight loss. Is it simply being at a lower weight? Or is it being a lower weight and healthy and physically active and happy with life? What do you think about that?

**Dan Bessesen:** Well, yeah. You're absolutely right. Lifestyle, though, has to evolve because lifestyle before diet and physical activity, what we were doing there, again, you guys have always done great lifestyle programs, but many people said to restrict calories to lose more weight. Exercise more thinking you'll burn more calories, you'll lose more weight, the focus on weight loss. With highly active anti-obesity medicines, the ones available now and coming, that's a very different world. It's like bariatric surgery in a shot. People just are not interested in food anymore. And when somebody in and goes, I think that framework of what bariatric surgery does is somewhat helpful but different.

Bariatric surgery gives a lot of weight loss and people are not interested in food. So now the question isn't restrict calories. It's become diet quality. But we're hoping for I mean, we know that eating a good diet, and we know what the elements of a healthful diet are. For many people who struggle with the weight, it's very hard to eat that healthful diet. Once you take appetite out of the equation, now people can start making lifestyle changes and get the benefits of a good diet. Same thing with physical activity. A lot of people struggle with their weight.

They just aren't able to exercise the way they would like. And now if they're losing weight now they're able to exercise. And so we know that physical activity is great for people's health. So how do we get people to exercise, and appreciate the value of exercise and diet for health benefits, not for weight benefits? And I agree with you. I think that's the future, but lifestyle our lifestyle interventions are going to have to evolve towards that.

**Holly Wyatt**: I think lifestyle now, may be playing a more role finally in weight loss maintenance. Then there are people who either don't want to stay on the drugs long term for lots of reasons or can't financially or want to get pregnant. I mean, so many different reasons why you may not stay on the drug and how can the lifestyle then come in and try to do the best it can, right, at helping maintain versus lose? So I think we're going to see more of that, which we've never been able to focus on weight loss maintenance because people have never really gotten enough weight loss to want to talk about weight loss maintenance.

**Jim Hill:** And now, Dan, people are hitting their goals. People are actually losing an amount of weight, which is what they want to lose, and we've never seen that on a widespread basis before.

**Holly Wyatt:** Well, I think it's exciting from behavior. I don't I don't see it as a threat. I think it's finally kind of exciting that we have this tool that's going to change the landscape, but it'll still allow us to really do things with life state or lifestyle.

**Dan Bessesen:** Yeah. And what is the goal? You Jimmy said people reach their goal. The fact that we're getting close to that raises the question of what is the goal. And we've had people enrolled in studies that the FDA says medications are appropriate for people with a BMI over 27 with weight-related comorbidity. So if you have somebody with a BMI of 29, and a little mild hypertension, does that person need 30% body weight? What is the proper weight loss goal for that person? How fast should they achieve it? And I and I also see people helped a lot of people with bariatric surgery, and there's a lot of psychological things that happen when people lose a lot of weight. People around them interact with them differently. Couples have challenges around weight when one partner loses weight. And so in bariatric surgery, we learned a long time ago that upfront you need to do some nutritional counseling, some psychological counseling. People go to support groups to know what am I going to look like after surgery, what are the challenges.

We do none of that for medications. We write a prescription and hope for the best, and then we're surprised that people are like, woah. The people at work are saying things. What do I say to them? My spouse is doing this, and what do I say to them? And surgery, it's a go-no-go sort of a thing. I either have surgery or I don't. But with medicines, you can tune it in, dial it in at a particular level. So it makes your question about achieving a goal. It focuses on the question of what's the goal for the patient and what's my goal medically.

**Jim Hill:** I think that's brilliant. And a follow-up to that that came to mind as you were talking, a lot of experts, some of our colleagues here would basically say, oh, these are medications only for people who are overweight with metabolic problems. If people just want to look better or lose 10 pounds to feel better, they shouldn't take the medication. I think Holly and I pushed back a little on that to say there are lots of reasons to improve your quality of life with weight loss. Thoughts about this one?

**Dan Bessesen:** What comes to mind immediately is resource allocation. Who gets medications, highly effective, and had obesity medications now? Elon Musk and Oprah Winfrey. I don't know Oprah Winfrey's medical history, but I know at my hospital Denver Health, I have a lot of people with BMIs of 40, 50 who don't have access to these medications. So at some level, right now, when the costs are high and insurance coverage is poor, it becomes a bit of a health equity issue in my mind, and it focuses too on this goal. think who stands to gain the most from expensive, highly effective medications. In the future, what's the world going to look like in 30 years? How many people want to lose some weight and the medications will provide it? I think our job is going to be in this area that you bring up. Are we going to say, I don't think this is right for you, or I think you're losing too much weight? That's a conversation I don't know that we're ready to have quite yet.

**Holly Wyatt**: And I think one of the ways it does differ from bariatric surgery now is you can get these weight loss medications online. You don't necessarily even have a doctor monitoring it. I mean, there may be one online, but not your doctor. Not not in a way that's really so it's it's even a step removed from that, I think. So, I think that opens a whole another box of things we're going to have to deal with and how we deal with these new medications. But I do think it's exciting to finally I think all of our careers we've been waiting for a tool that can produce weight loss in this range, and I think we finally have some.

**Dan Bessesen:** I think your comment about online is a really important one. One of the things we've started working on in conjunction with another society is the standards of care for obesity treatment. Every organization wants to have their own guidelines, but I think it would be great if all our societies could work together and do something like what the American Diabetes Association has done with diabetes, which is to answer those practical questions that clinicians really face every day. And as we talked about what topics are very important, one of the top ones was telehealth because telehealth is a wild west out there right now. My own view is that people who struggle with weight are a bit of a vulnerable population. They're very worried, but they're not getting the support they need from their doctors. And there's always going to be a market, people who are ready to make some money off of people who, are a vulnerable population.

There are some great telehealth programs, and there are some less good telehealth programs out there. This is one of the places where I think you can work with your doctor, your listeners, to sort of say, if you're not comfortable doing this, I looked online, and this is what I found. Do you think this is a good program or not? How can you work with these people? I don't want to go around you. I'd like to work with you because that's what the telehealth people don't have. Maybe they got a prescription blank and a link to your insurance company, but they don't know your medical history. And so I think that's why your doctor, even if they won't prescribe or are uncomfortable prescribing, needs to be looped into this care plan.

**Jim Hill:** I have another question before we get to the listeners, and that's what you talked about, Dan, is equity and access, and we don't have that right now. And part of it is the health care system is still adjusting to how they handle these. Holly and I talked to the insurer for UAB, and they're frightened. They basically said if we covered everybody who was qualified, your premiums would double or triple. And you're going to tell me that we've dealt with these things all along, but how do you see the Hill care system, evolving so that people at Denver Health with BMIs of 40 and 50 who need the meds can get them and get them covered?

**Dan Bessesen:** This is such a hard one. Here in Colorado, our local insurance covered all these medicines for about 10 months, and then they abruptly withdrew that. Oh my god. It was such a mess. And we've seen this at several state levels. I think North Carolina has undergone this. Advocacy groups say these medicines are critical. This is a disease state. People need these medicines, and we should give them to everyone. And naively, I would say, people said, okay. Great. Let's do that. And then as soon as they see the numbers, they're like, this does not work. From my perspective, we cannot have access to these medicines for everybody who would benefit from them. It's just financially not possible right now.

**Jim Hill:** Really interesting data.

**Dan Bessesen:** And so I think we either say, everybody should have them, and then the insurers say no one can have them. There's a lot of ground between everybody and nobody. And I personally think it's the job of those of us who think about this a lot to really engage in this discussion. And to do that, I think personally that we need to have more data. We need more actual research. I mean, the cost-benefit stuff that's been happening, it's just made-up stuff. You can get whatever you want from a cost-benefit analysis, but we really need, I believe, our pragmatic trials where drug companies work with insurance groups, employers, and government research agencies to collaborate and collect actual data. Let's use a strategy. Make it up. Jim, you're good at thinking up in a fate of thanks. Holly, you too. Just say, here is a rational way to prescribe these. Okay. Let's do that at at the, at this insurance company and the drug companies, you have to pitch in some drug at a reasonable price. We'll get academic people to do the cost-benefit analysis. I mean, we got AI for goodness sake. There's so much data around. Let's really understand who is going to benefit and what the cost implications are. Now we're not making it up. We're not making political statements. We're gathering data that will really answer these important questions.

**Jim Hill:** I love it. And that's a powerful statement, but I think it's an important one. Not everybody who needs these meds is going to get access to them, and that's not likely going to change anytime soon.

**Dan Bessesen:** It's going to be years years. It will change eventually, but not for a while.

**Jim Hill:** Holly, I have one more question before we get to the listeners. Alright, Dan. What do patients get wrong when talking to docs about their weight?

**Holly Wyatt:** Oh, this is a good one. Waiting for Dan on this one.

**Dan Bessesen:** Visits I have trouble with, again, goes back to the opening. I think some patients have their own agenda. They don't want to hear the data. They think this is what I want, and you just need to execute on. I need this prescription at this dose. Send it into this place, period. And I think people get a lot of information from the Internet and television and that's fine. But what the information I have is a human being in front of me and their medical history and medical record.

So I think some patients don't value what I have to offer or their primary care doc. Their primary care docs Hill are great. So I think some patients don't engage the medical system. I think the other thing that patients sometimes get wrong and, again, wrong is a harsh word. We all have our own realities. And, so I think some people continue to blame themselves for their weight. They continue to think that this is my fault, and so I don't deserve care. I don't think that's a helpful idea.

I think I believe that weight is a biological problem and that nobody chooses to struggle with their weight. I talk to thin people, thin legislators, and thin insurers who say, oh, you just need to exercise more and eat less. And so I show them my picture, Jim, of what happens to rats' weights over their life. And if you overfeed a rat, it can gain the weight. But when you stop the overfeeding, it goes down to where the weight wanted to be and vice versa. So what I say to these thin legislators, I said, what if I told you that medically, you have to gain 150 pounds by overeating, and you need to do that for the rest of your life? If that was the situation, would you be able to do that? Would you be able to eat so much that you gain 100 pounds for the rest of your life? I don't think you could, but that's what you're asking these people to do. You're asking people to push back against really powerful biology.

So what do patients get wrong? Though on the two sides, I think people shouldn't blame themselves. That doesn't help the conversation. And they also, I think, shouldn't just have an agenda and not be open to what their clinician has to offer.

**Jim Hill:** So be flexible when you go in and have the conversation with your doc, and maybe you get a solution, but it might not be the solution you came in thinking you were going to get.

**Dan Bessesen:** Well put. Yeah.

**Jim Hill:** Okay, Holly. Listener questions.

**Holly Wyatt:** Listener questions. Some of these we've touched on, but I think it's worth going back because I think a couple of these are common questions I know. This first one's from Hill, and she says that her primary care physician doesn't really believe in the weight loss medications or maybe doesn't feel comfortable prescribing them but really doesn't want to talk about them, she would like to try them. What could she do? What should she say? I mean, what are the options for her at that point? She wants to try them. The doc says, nope. Either think they're good for you or I don't I don't think they're an option for you.

**Dan Bessesen:** I think there are a couple of choices there. One choice would be to say, this is not a doctor that I want to work with, and I want to find a new doctor. I would say to evaluate that option, you got to look at what else is this doc doing for you. Is this doctor helping your health generally or not? And I think each of us needs to work to find a clinician that we can productively interact with. So one choice is to pick a different doctor. Another choice would be to say to the doc, I think this is a possibility. The FDA has approved these. Many people are using these. I would like to learn more about these. I'm going to look for another place to do that, but I would like to keep you involved in this. Is that okay with you? Do you have somebody that you would suggest I go to? What do you think about online things? What do you think about any doctors in your practice who do more of this? How about an obesity medicine specialist? What do you think of that? You're there in the office. You paid the co-pay. Just have a conversation and try to get something useful out of it.

**Holly Wyatt:** I like that. See, I think that to ask what the other options are, I think, is a nice kind of in-between solution to that. Alright. Here's a common one. I know you've heard this question before. This one comes from Barbara. She talks about how her doctor always blames her weight on all of her medical issues. We're switching over a little bit. So every time she goes in, she may be coming in for something, some pain or something, but it always kind of goes to this is a weight problem. His advice is always to lose some weight and then we'll see how you feel after that or that's the solution to the problem. What could she say? What could she do in this situation?

**Dan Bessesen:** Conversations are the same in all aspects of other life. I am an old person I know, and there's a power dynamic between doctors and patients. Patients feel like that or they used to feel like doctors had the power and they didn't. But I think open, honest communication is always helpful. And so the doctor's trying to serve you. You are you are the customer in this relationship. So if you feel like what the doctor is saying is not and doesn't align with what you want, then say what you're thinking. In this situation, I'm not exactly sure what's behind the comment. It sounds like this person, I would take from the comment is the person wants the doctor to focus on the health problem, not focus on her weight.

**Holly Wyatt:** I think that's it. Yeah.

**Dan Bessesen:** And so I think what the person can say is Holly, I need you to help me with these specific health problems and not talk about my weight. I've tried my weight, and I know my choices. And that's not what I want us to focus on today. Please talk about my health problems and what my choices are besides focusing on my weight. You don't have to be judgmental. You're just being honest that what they're saying is not helpful. The doc has 1 or 2 choices. They can respond to that, and that's what a good doctor will do. But if they don't listen to you, I think you need a new doctor.

**Holly Wyatt:** See, there we go. Yeah. That's what I love. I coming down to the nitty gritty saying, sometimes you have to get a new doctor.

**Jim Hill**: Let's do one more. This is from Jen. All these are women, Holly. Don't we get any questions from men?

**Holly Wyatt:** No. Men don't don't like to ask questions. They don't need help. They don't think they need any help. So there's our way.

**Jim Hill**: Okay. Jen says, when I ask for help with my weight, my doc tells me, well, just eat a little less and move more and you'll lose weight. It isn't working for me. What can I do?

**Dan Bessesen:** Again, I think ideally, if you can say simply, well, I've really tried that. It's not working for me. Are there other options? For those people listening to this podcast and who know you guys, there are other options. There's bariatric surgery if your weight is over some level and that's a moving target, and you have co-health problems or medications. So at that moment, if the doc says diet and physical activity, it is fair for you to say, I'm working hard on that as you know I've you and I have talked about this before. I'm interested in learning more about medications. I hear about medications. Is that something you're comfortable talking to me about? Because that's where I need information.

**Jim Hill**: Great. Great. Holly, do you know what time it is now?

**Holly Wyatt:** Yes.

**Jim Hill:** It's time for the personal questions.

**Holly Wyatt:** Yes. We're calling it let's get real.

**Jim Hill**: Let's get real. I'll ask 1 and then you ask 1.

**Holly Wyatt:** Okay.

**Jim Hill**: So, Dan, you and I met in 1992. Your hair was much, much darker.

**Dan Bessesen:** Had more hair.

**Jim Hill**: You were seeing patients. You were very interested in this issue. What do you do differently now? What have you learned since then that you apply in your practice?

**Dan Bessesen:** Holly, you were just so gracious and kind talking about, how I work with patients. I didn't know any I didn't know how to talk to patients then. I had been raised with the idea that I'm the boss. They're the patient, they need to do what I say. And what happened was that didn't work. Those were not useful, productive conversations, and so nobody exactly taught me how to talk to people. It's something I read about and listened to thoughtful people. And then over the years, I sort of, found that there is a natural way that I talk to people that I just enjoy my conversations. And some of it is each person I see, I don't know the right way to say this. The words that come to mind are I see the thin person inside them, not their weight. But it's not a thin person because they aren't their weight. I see a person in front of me who I don't know anything about and I'm curious about who they are. And people are just infinitely interesting. And so what's different, I don't think that I have all the answers. What I have now that I didn't have then is a deep desire to have a meaningful conversation with the people I sit with. That's what's different.

**Jim Hill:** And I will also say, Dan, I've seen you teach so many other physicians how to do that. You are really gifted in taking these sensitive issues because you see both sides of it. I remember you giving a talk on medications early on, and you said, I struggle with this. I feel so you've done a masterful job, I think, of educating the physicians about this issue. And I think because of you, in large part, that there are more physicians open to having these conversations.

**Holly Wyatt:** I know when I first started, there was part of me that felt like I need to teach the patient something, or if they said something that wasn't exactly right, it was my job to tell them that was wrong and explain it. But that didn't get me very far necessarily. They're not there necessarily to learn about their resting metabolic rate and that it is higher than they think it is, that this closes the door and they don't even hear what I'm saying after that. It just has a different relationship. So I think really what you're talking about is you figured out how to have this relationship with the patient that is beneficial to both sides to really move things forward. And I think that's part of what you taught me. The other thing I was just having a flashback as you were talking is I used to come out of a patient's room and I would have taken on all their problems. I would be like, oh, Dan and this and they don't have money and this is the problem, this is the problem, this is the problem, this is the problem, and you'd be like, woah, Holly. You just caught what we'd call the weight ball, the problem, or whatever it was. You caught it. It's not yours to catch. We're here to help. Go back in. Say it differently. And you would have me literally go back in and rehab a conversation. And that's how I learned.

**Dan Bessesen:** One of the things I learned recently, Jim, we did that conference on sustaining behavior change, and now I'm blanking on the guy's name who kind behind motivational interviewing and stuff. One thing he said in his talk that just stuck with me in the last couple of years was he said, you know what predicts whether people will change their behavior? It's not whether they, whether they like the doctor. It's whether they think the doctor likes them. I think that was just powerful. Because I think sometimes I see docs come out of the room shaking their head or they look at the name on the chart, and they just go, oh, it's miss so and so or mister so and so's back. Oh my god. This is going to be a disaster. I literally think it's a lot more fun for me to have a conversation with somebody I like. And the people I see at Denver Health, many of them live such challenging lives, but each one of them, there's just something to like about them. So I must say it makes my clinic go faster to sort of say, I'm going to approach this person like a friend. This is somebody that I like, and I just be helpful too.

**Holly Wyatt:** And the fact that you can always learn something for every single patient. If you go into the open that I don't know everything and it's true and I can learn something, I think that just puts you in a whole different space. So that's something that I like to do too. Alright. I've got a personal question. Another one. So, Dan, you're a lean guy. I don't think you've had a weight problem or I've never noticed that you have a weight problem. Does that ever come up in your weight conversations? How do you have insight into the struggle? Do the patients ever point that out that, yeah, doing these behaviors may be easier for you than it is for them, for instance?

**Dan Bessesen:** Maybe I'm not as lean as you remember me. But, no. I must say, as you asked the question, I don't know that I've ever had somebody bring up my weight in the conversation, and I think, I don't know what the experience of a person who struggles with their weight is. And I will say that not infrequently. I'll say, or I'll say something like, this is really hard. I know I've seen a lot of people who struggle with their weight, and it's just really hard to do this. And that makes sense to me understanding the biology like I do. So, no. I don't understand the lived experience, but I've listened to so many stories. I feel like I can reflect to people what I've heard from others, and the stories are so consistent. You guys hear this all the time. People who, live in larger bodies are just viewed differently. There's a lot of stigma and bias out there. And I think maybe if I just treat people with respect and talk to them like anybody else, I think maybe they have a perception that the weight's not the issue here. It's what can we talk about today.

**Jim Hill:** Wow. Alright, Holly. We always end with the segment that Holly calls pie on the plate as opposed to pie in the sky. It seems to me like one of the big takeaways is your physician needs to be your partner here. It's hard losing weight and keeping it off. And unless you engage your physician as part of your team, you're not taking advantage of a tool that is available to you.

**Dan Bessesen:** Super well said. Absolutely. And you can do that by being an active participant, and that means coming to the office prepared. And Holly knows this too. I mean, I think on the doctor's side, we have things that we say, and I push the button, and out comes these things I say that I find tend to get things going. So I think we've talked about some of those today. When you go to the doctor, come prepared. If you want to talk about your weight, raise the flag and say, I'm hoping we can talk about my weight sometime today. If the doctor says, I don't prescribe those medicines. It's a short-term fixate. I'm, interested in learning more about them. Sounds like maybe you’re not wanting to talk about that. That's okay. You're my doctor. You give me a lot of useful stuff, but can you refer me to somebody who maybe can help me understand more about the pros and cons of this medicine? I want to keep you on my team, but I need more information about this.

**Holly Wyatt:** Love it. Such practical stuff. Good pie on the plate. That's exactly what we wanted to end on.

**Jim Hill:** Dan, thank you so much. This has been a wonderful conversation. And again, thank you for everything you've done over the years interacting with us. We published together. We've, we've celebrated the highs and the lows together, and you really have made a difference. Maybe before we leave, what's next for you? What did the next few years bring for Dan Bessesen?

**Dan Bessesen:** You're never going to retire, Jim, you know. So I wonder what the future is for me. I love spending time with my wife and doing things outside of work. I love the research that I do and the clinical things, but I'm actually not sure. I do think these standards of care project is something I'm really excited about. I think the field could really use some practical advice, for clinicians, so I'm interested in doing that. And we're going to keep doing some of our research on reduced obesity, so I got a few more years.

**Jim Hill:** Well, you've made a difference, and I'm sure you'll keep making a difference. It's been wonderful, my friend. Thank you and thanks everybody for listening to this episode. And we will talk with you on the next episode of Weight Loss And.

**Dan Bessesen:** See you guys. Such a pleasure. Bye bye.

**Holly Wyatt:** Thank you, Dan.

**Jim Hill**: And that's a wrap for today's episode of Weight Loss And ... We hope you enjoy diving into the world of weight loss with us.

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**Jim Hill**: We'd also love to hear from you. Share your thoughts, questions, or topic suggestions by reaching out at [weightlossand.com](http://weightlossand.com/). Your feedback helps us tailor future episodes to your needs.

**Holly Wyatt**: And remember, the journey doesn't end here. Keep applying the knowledge and strategies you've learned and embrace the power of the “Ands” in your own weight loss journey.