Weight-loss pills; breastfeeding help: Upstate Medical University's HealthLink on Air for Sunday, Oct. 29, 2023

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air," we'll explore the safety and effectiveness of some heavily advertised drugs that have become popular with people seeking to lose weight.

Timothy Shope, MD: ... We don't know how long patients can be on these medications. We don't know everything that might happen to them once they stop taking the medications, although there does appear to be some weight regain afterwards. But yeah, they do actually help folks lose some weight. ...

Host Amber Smith: And we'll learn about new support for moms with questions about breastfeeding.

Jayne Charlamb, MD: ... Just as there are some women that have issues with infertility, there are some women that have issues with developing the milk supply. And I think we have ability now to support those families and fix some of the issues that they did not have thousands of years ago. ...

Host Amber Smith: All that, plus a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith.

On this week's show, a new way to get answers about breastfeeding, from a doctor and a nurse who are international board-certified lactation consultants. But first, are weight-loss drugs safe? Are they effective? Upstate's chief of weight-loss surgery will discuss.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

A couple of medications have become popular lately for helping people lose weight. Do they work? Are they safe? I'll cover that and more with Dr. Timothy Shope. He's the chief of bariatric surgery at Upstate.

Welcome back to "HealthLink on Air," Dr. Shope.

Timothy Shope, MD: Well, thanks, Amber. It's great to be back with you.

Host Amber Smith: Ozempic and Wegovy have been in the news lately. And if I understand correctly, both of these drugs contain the same active ingredient. Can you tell us about it?

Timothy Shope, MD: So the medications are in the class called "semaglutides." This is basically the medication form of a naturally occurring GI (gastrointestinal, or digestive) tract hormone called GLP-1. That's glucagon-like peptide-1, a medication that causes a response in the body similar to what that hormone does.

Host Amber Smith: So, semaglutides. I've never heard of that. How was this discovered, or how long have we known about semaglutides?

Timothy Shope, MD: These hormones have been around for a long time. The development of them as a medication, it's kind of a long story. It starts back in the ... actually in the 1980s, with researchers that were working on diabetes, essentially. They were looking at one of the hormones that regulates diabetes, it's called glucagon, and in that process they discovered GLP-1. And that specific hormone causes a very idealized response in the pancreas, just on the cells that make insulin. They tried giving it to patients, but it didn't work because, basically, it got degraded in the body before it could get to where it would have its effect.

About a decade later, another researcher found a variant of GLP-1 that lasted longer, and, interestingly, he found this actually in the saliva of the Gila monster that lives in our desert Southwest. We knew for a while, I guess, that Gila monsters were able to keep their blood sugar levels pretty stable, even when they had some relative starvation -- hard to find food out there, I guess.

So, they found this hormone in the lizards' saliva, and some modifications, obviously, led to the creation of the first one of these medications, called Byetta. This was used to help control diabetes, but it did need to be injected twice a day. Researchers were trying to figure out ways to make it last longer, so by the 2000s, a medication called liraglutide, this is really the first of things that led to semaglutide, was developed, and it really only needed to be injected once a day. It was FDA (Food and Drug Administration) approved for management of diabetes and was marketed as a medication called Victoza.

These medications were found subsequently to have a modest effect on weight loss.

By the time the late 20-teens came around, the medication had been modified to last longer and really only needed to be injected once a week, and this is now what we know as semaglutide.

The first of these was marketed as Ozempic, as you already mentioned. It can't be prescribed, or claimed, to promote weight loss, but I think many of your listeners have seen the advertising or heard the advertising that includes weight loss as a side effect.

So that's really sort of the long story about how these medications came to be, from 30-35 years ago.

Host Amber Smith: So are these prescription medications at this point?

Timothy Shope, MD: They are prescription medications, yes. They can only be obtained by prescription.

Host Amber Smith: And insurances, I guess, are covering them then?

Timothy Shope, MD: Well, so it really depends. Most of the insurance companies will only cover them if the patient is also diabetic; remember that these medications are essentially diabetic medications.

There is one medication that has been approved, for use as a weight-loss medication, but even that has to be approved by the insurance company. And there's usually a pre-authorization process that we have to go through for the patient.

Host Amber Smith: So it's not as simple as walking into the pharmacy and grabbing it off the shelf.

You have to have a relationship with a physician to get the prescription, and it seems like it's involved.

Timothy Shope, MD: Yeah, that's correct. I mean, no more involved than any other medication, although again, since it's newer, there may be some work that needs to be done to have the insurance company approve coverage for it.

But yeah, it's like any other medication that can be prescribed.

Host Amber Smith: Do they actually help people lose weight?

Timothy Shope, MD: They do. Again, not all of them are necessarily designed to do that, so it's essentially sort of a side effect of these medications. The weight loss is modest. It's not great, but it's definitely better than doing nothing, and we don't know how long patients can be on these medications, per se. We don't know everything that might happen to them once they stop taking the medications, although there does appear to be some weight regain afterwards. But yeah, they do actually help folks lose some weight.

Host Amber Smith: Are they safe to take if you don't have diabetes?

Timothy Shope, MD: Well, "safe" is kind of a loaded question. The FDA approved them, so it has to go through some rigorous testing to prove that it's safe for a patient to take. But there's certainly some side effects. There's a lot of GI tract issues that can happen for folks: nausea, vomiting, some abdominal pain. Some folks will get constipation or diarrhea. One of the ways the medications work is by creating a sense of being full. And so there's sort of that constant sense that "I'm not hungry" and "I'm bloated; I'm a little distended" kind of sensation.

Most of the time that goes away a little bit, but that's not anything that's unsafe. It's just maybe not exactly what the patient was looking for. There are some reports of problems with issues with kidneys. And importantly, if you remember that these medications are designed to help patients manage diabetes, it could make someone's blood sugar be very low. And so the patients, especially those that aren't diabetic and have never understood what it's like to take insulin or have a low blood sugar, they need to be coached about that and make sure that they understand what to look out for and what to do if they have the symptoms of hypoglycemia, or low blood sugar.

Host Amber Smith: Do the medications work differently in someone who has a lot of weight to lose versus someone who's got just a few pounds they're trying to shed?

Timothy Shope, MD: I'm not sure what you mean by "work differently."

Host Amber Smith: Well, someone who has 50 pounds to lose, is the medication going to help them lose that as well as it might help someone lose 10 pounds?

Timothy Shope, MD: Yeah, I think so. the data that we understand is that these medications will largely help patients lose somewhere between 10% and 20% of their total weight. So if someone weighs 300 pounds, that would be 50 or 60 pounds. If someone weighs 200 pounds, that would be, you know, 30 or 40 pounds, per se.

So it's really just reflective of whatever starting weight they have and that somewhere between 10% and 20% of that total weight.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith.

I'm talking to Dr. Timothy Shope. He's the chief of bariatric surgery at Upstate, and we're talking about drugs that people may take to help them lose weight.

Let's go over some of the common negative side effects for people who take these medications. You touched on a few of them, but what are the most serious potential side effects?

Timothy Shope, MD: So the serious side effects, again, are those that may lead to some problems with a patient's kidneys and the effect that it has on blood sugar, especially if someone's not prepared to understand what it means to have low blood sugar. When the sugar drops precipitously, a patient could pass out.

And if they're obviously engaged in some physical activity or driving a car or work, that kind of thing, that could be potentially dangerous for them. There have been some reports of some other types of really serious problems, but it's not clear. Those reports came in patients that were on this medication, or these medications, but it's not clear that the medication caused those problems.

Host Amber Smith: Now, what about the idea that these medications might reduce heart attack or stroke risk? There was something in the news recently about that. Has that been borne out?

Timothy Shope, MD: There's clearly some cardiovascular benefit to losing weight, managing your diabetes, to getting control of your other weight-related medical problems.

So if patients are generally losing weight with these medications, they're going to reduce problems with blood pressure, problems with cholesterol, sleep apnea, all those medical troubles that we know are definitely related to morbid obesity.

Host Amber Smith: Are there things a person can do if they're taking these medications to help minimize the side effects or to help maximize weight loss?

Timothy Shope, MD: The only thing that can really be done to minimize some of the side effects is to essentially slowly ramp up on the dosage of the medication. If you start the medication at a higher dose, it's almost a promise that you're going to have some of these side effects. By starting at lower doses, it allows a body to sort of accommodate to the medication over time. It can be a little frustrating for patients, I suppose, because usually, every month we would then increase that dose, and they may not get the effects of the medication with regard to weight loss that they're looking for until we get to a higher dose.

So there may be some lag in the weight loss associated with the efforts to minimize those side effects. I'm not sure that there's any way that they can maximize their weight loss other than doing the things that we would otherwise suggest: proper healthy diet, exercise, things that we emphasize for every patient that's trying to be serious about weight loss, including our surgical weight-loss patients.

Host Amber Smith: What happens when a person stops taking the medications? Are these meant to be lifelong drugs, or can they take them for a while and then stop?

Timothy Shope, MD: So some of it, we don't really know the answer to that. Ozempic, I know, has been, not marketed, but sort of suggested, to be something that a patient can be on for life.

I think you have to be pretty smart about stopping these medications, and I don't think a patient should do it on their own. Obviously, this is a medication that's prescribed by a medical provider, and you should definitely have that discussion with that provider. Particularly if you're on it also for management of diabetes, your sugars may be a problem if you stop it.

We do know that there is a weight regain in almost every patient, actually, once the medication is stopped. That weight regain can be at least half, maybe two-thirds, of the weight that was lost within a year of stopping the medication.

Host Amber Smith: Now, you care for patients who are considering surgery after struggling to lose weight.

Do you ever recommend these weight-loss medications before surgery or in combination with surgery?

Timothy Shope, MD: We do, actually. We see patients for both surgical and nonsurgical weight loss. Obviously, as surgeons, we have a preference there, but we want to make sure that we have options for our patients.

And our program does incorporate these medications for patients who aren't yet ready for surgery. They're not yet there, emotionally or in their life, but they don't want to go through that process. If they ultimately don't achieve the weight loss that they need, many of them will then consider surgery.

But in the meantime, these medications can help with some weight loss. They can modify some of those medical risks that the patients would have. Some surgeons are using these as adjuncts to weight loss, meaning that we can give the medications after an operation. There's actually some data that shows modest weight loss for patients that start these medications years after their weight-loss surgery.

You can use these preoperatively for a couple of reasons. Again, that's going to help patients lose weight, which decreases their surgical risk, may help them control their diabetes better, may improve their other medical troubles before surgery. So programs are using them either as a stand-alone option, as a way to prepare, to get ready, for surgery, and then as an adjunct after surgery to facilitate some additional weight loss.

Host Amber Smith: Has the effectiveness of weight-loss surgery been compared with the effectiveness of these semaglutides?

Timothy Shope, MD: There's one clinical trial that's out there, so it's not yet -- I can't say that it's -- definitive, but there's one clinical trial that, a medication called tirzepatide, which has been marketed as Mounjaro, and in the patients that did not have previous weight-loss surgery, they had outcomes that were close from the standpoint of weight loss to those that did have surgery instead of being on that medication. This medication's a newer version of these things. It adds another hormone called GIP, or gastric inhibitory peptide, to the GLP-1 hormone, and so the combination appears to be pretty effective. The issue is, there's really not a lot of long-term data on this.

Host Amber Smith: Let me ask, if you would, can you describe who the ideal surgery candidate is for weight-loss surgery? How do you help someone decide whether they're ready for that?

Timothy Shope, MD: Sure. I mean, I think they have to decide that for themselves first.

They have to be in a good place in their lives, where they're committed to this process. They have to be someone who meets the criteria, meaning they have a certain body mass index, or BMI, they have certain medical troubles that they need to address with this.

And they have to have tried something else first, right? We can't just go jump right to surgery. So, the nonsurgical weight-loss options that are out there, they should have tried and ultimately not had success with, hopefully, more than one of them. The unfortunate truth of those programs is that the number of patients that have a sustainable weight loss with them is actually very low, so a lot of patients will ultimately opt for surgery, which does have a much better long-term outcome with regard to not just losing weight, but keeping it off.

Those patients that then decide that they'd like to consider surgery, that's when we usually see them, once they've sort of exhausted those nonsurgical means. They've worked with their primary care doctors or their endocrinologist or other doctors, and they say, "Look, I need some extra help here."

When we see them, we have discussion with them about the process. And that's the reality of this, is that surgical weight loss is a process. It's not (just) an operation anymore, so there's several months of a preoperative process that the patients go through, working with registered dietitians, learning about things that we probably already know, but if you're like me, don't always put into practice. Things like reading product labels, meal planning, these kind of things, when we just kind of grab and go these days.

But if they can incorporate those types of behaviors into their daily lives, and they can commit to them, they can modify, to the best that they can, their other medical troubles, then they're somebody who would be a candidate for surgery.

Host Amber Smith: Well, we talked about the side effects of the medications. Are there side effects of weight-loss surgery that people should be aware of?

Timothy Shope, MD: Sure. I mean, any surgical procedure carries some risk. When we talk about risk of surgery, that's really sort of that perioperative period, or the first 30 days or so after surgery.

But I think you're really more talking about sort of the long-term outcomes of surgery, right?

Host Amber Smith: Yes.

Timothy Shope, MD: Yeah, so, over time, patients can have problems with excess skin. There are certainly some behavioral or psychological issues that can arise, meaning we don't do any operations that change relationships with food. We don't do any operations that change your family's relationship with food, so if there's other folks in the house, there may be some issues with regard to meal planning for everybody, making sure that there is not easy access for the patient that's undergoing these procedures to foods that would subvert the process.

So there's a lot of potential psychosocial issues that really are there in the long term.

The medical issues long term: There can be some modest weight regain. It's not usually to the degree that we see from stopping the medications, for example. Usually the medical problems that have been resolved with weight-loss surgery, most of them stay resolved unless there's a substantial weight regain.

And I think there's just some hesitancy sometimes on the part of patients to come back to their weight-loss surgery program if they have regained the weight. And that's not the right way to think about this. I mean, we're here to help these folks long term, and should they come back to their program, usually there's something we can do to help them turn that around, at least re-lose much of what they had regained.

Host Amber Smith: So it sounds like no matter which avenue you take, this is not a quick fix.

Timothy Shope, MD: No, it's not. Absolutely not. This is not the easy way out. It's not a quick fix. Surgical weight loss is, as I said, a process.

And to me, the surgery is really the start of that process. I mean, you have to do a certain number of things to get there, obviously, but really that day of surgery is when things start. And it's how you use that new tool that you've been given to get those results that you're looking for. And working with your program, working with the dietitians, really just sort of keeping those modified behaviors as part of your daily life for the rest of your life is key to the long-term success.

The medications, again, there's some potential side effects. We don't know some of the long-term aspects of these things, so it's possible a year or two from now we'll find that we have to actually stop them after a certain length of time. We don't know.

So it's not an easy or a quick fix, any of it.

Host Amber Smith: Well, Dr. Shope, thank you so much for making time for this interview.

Timothy Shope, MD: Sure. Anytime.

Host Amber Smith: My guest has been Dr. Timothy Shope. He's the chief of bariatric surgery at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Answers to your breastfeeding questions, next, on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Upstate's breast health and breastfeeding medicine division has expanded its services with a public phone number dedicated to lactation assistance. I'm talking with the director of the division, Dr. Jayne Charlamb, along with nurse Michele Dwyer. Dr. Charlamb is an associate professor in internal medicine and obstetrics and gynecology at Upstate, and nurse Dwyer is a nurse with more than 30 years experience in maternal child health care. Both are international board certified lactation consultants. Welcome to "HealthLink on Air," both of you.

Jayne Charlamb, MD: Thank you. It's a pleasure to be here.

Michele Dwyer, RN: Thank you, Amber.

Host Amber Smith: Why is it important to have a phone number that anyone can call to get answers about lactation ... Dr. Charlamb?

Jayne Charlamb, MD: You know, I think for a long time our medical community promoted breastfeeding but didn't do enough to support our families who wanted to breastfeed. And it's difficult sometimes for families to know where to go for help. Their pediatrician may not be available 24/7 or may not understand some of the aspects of breastfeeding not directly related to the baby, and the obstetrician may not have that specialty training on how breastfeeding works in terms of the baby.

So we felt that it would be great to have a one number place that would be easy for families to reach the breastfeeding support they need.

Host Amber Smith: So the number -- 315-464-MILK, or 6455 -- during what hours is that available for people to call?

Jayne Charlamb, MD: That's available 24/7. You are not going to get a live person on the other end 24/7, but there is a recording explaining where you can go for help during normal business hours. And if you do need help during the off hours, if it's an emergency and it can't wait, there is a number that we give that you can talk to a live person anytime, day or night.

This is for any family. We really encourage families, regardless of where they delivered their child, to call and get support. If a family needs to be seen in person, then we make it work.

Host Amber Smith: How often do people who call end up having an in-person appointment?

Jayne Charlamb, MD: I think I'm going to let Michele answer that because she is our best go-to as far as responding to phone calls.

Michele Dwyer, RN: As far as the percentage, I would say at least 50%. Many times I can triage on the phone, and it's a quick question; it's a quick answer. Maybe I'll be on the phone for 15 minutes, and I will literally be just helping that mom, so she can put the phone down and go back and take care of herself and her family. If it gets to be a little bit longer than 15 minutes, I can kind of feel it out that to best help you and best serve you, let's make an appointment. Do you feel like you could do that, and come with a support person?

So a fair answer would be 50%. I would like it to be 70% because it would be easier to evaluate a problem in person, for sure.

Host Amber Smith: Well, Dr. Charlamb, if I understand correctly, this number existed before, but it was just for physician use to call you, because you're one of a few physicians in New York state to be an international board-certified lactation consultant. So what sorts of questions would you typically get from your physician colleagues about breastfeeding?

Jayne Charlamb, MD: Very often physicians, honestly, would use that number to call us to say, "Hey, how can we get our patients to you?" And that's when we realized, wow, we really should establish something for the general public.

But physicians often have questions. I think most of them revolve around procedures and medications and whether or not they would be safe for their patients to use in a situation in which mom is breastfeeding and may need a certain antibiotic or a certain type of surgery, and how would that impact breastfeeding?

Interestingly, the vast, vast majority of medications are actually very compatible with breastfeeding, and I think there's a lot of concern -- rightfully out there; we never want to do any harm -- but I am very often able to reassure a medical provider or a family that that medication is just fine. And usually the answer is, it's just fine, or we can find something that is a safe alternative.

Host Amber Smith: Well, let's talk about the benefits of breastfeeding for the baby ... Nurse Dwyer?

Michele Dwyer, RN: A multitude. Coming off of the recent pandemic that we had, breastfeeding -- and we knew this was going to happen; Dr. Charlamb and I talked about this early on in the pandemic -- that early immunity and protection is most likely going to enter into the breast milk. And what better way to bolster up our civilization is to pass along the immunity via the breast milk, to the babies that were being born, coming into this situation.

And that did happen. The antibodies were found in the breast milk. I believe babies, they had immunities. I believe that was also found as well, babies that were nursing at the breast. That would be the first situation, I would say, that you're just passing along all of your good things to your baby.

And I tell my mothers that every time your baby gets any drop of your best breast milk, just like you are inoculating them to all of the situations that are out in the world. And that is a very empowering and very helpful piece of knowledge for a mom because she does put a lot pressure on herself.

Another benefit would be just that you're able, you made this baby for nine months, and now this baby is born, and you're going to bring this baby to the breast and give the most perfect food that has been specifically made for your infant, as opposed to if you were going to nurse another infant that was not yours. And it's just a full circle. And you're going to nurture that baby and provide nutrition. And essentially your baby is going to grow with the milk that you're providing. And it's a very empowering thing for a mom to see.

It just brings the whole maternal child full circle, I believe. So many, many benefits. Those would be my two biggest, is that you're just bolstering your baby to face the world and everything that is in it, and you're also nurturing that bond with your baby.

Jayne Charlamb, MD: I think building on that, looking at the results of that type of relationship, we look at the immune function that Michele mentioned is huge. We know that the baby's immune system is immature when that baby is born, and this helps the physiologic growth and development of the immune system, protecting against infection.

We know that babies that are breastfed are less likely to get chest infections, ear infections, diarrhea. Over the longer term, even when we're talking in terms of months of breastfeeding, we know babies will be having a significantly lower risk of dying of SIDS (sudden infant death syndrome,) and that's something that I think every family is very fearful of. And if they want to do everything possible, that's a very empowering, good way to reduce risk of SIDS.

Certainly we see reduced risk of leukemia in infants. And getting older even, there are some indications that infants that are breastfed for at least one year, when they are older, less likely to develop obesity, which in our current atmosphere of concern about this epidemic of obesity, to be able to set up one's child to have less likely to have problems with that is a really wonderful thing.

Host Amber Smith: Are there benefits for the mom?

Jayne Charlamb, MD: Oh, 100%. As Michele mentioned, I think the bonding is a big part about it. There's the ease relative to having to wash bottles and sterilization in the early days.

From the medical standpoint, though, we're starting to have a growing understanding of benefits to mom that we didn't really acknowledge or understand years ago. We know that women who breastfeed are less likely to develop breast cancer, are less likely to develop ovarian cancer and even heart disease.

That seems to be a growing acknowledgment in the medical community that, of course, I think the general medical practitioner at this point understands fully that breastfeeding is good for baby, but we're now starting to get a better understanding that, wow, this is really important for moms as well.

You spend, as Michele mentioned, nine months growing this human inside of you. And there are many, many changes that go on in a pregnant person's body, including laying down fat stores and changing the way our glucose, our sugars are stored, and our metabolism works. And all of that really is nature's way of preparing this adult body to breastfeed.

And if we halt that, after delivery, if we say, OK, we're just going to get formula and not go through that lactation stage for that woman who just delivered an infant, that's not the physiologic norm. That's not what her body was set up to do. So there are repercussions to that which we can see -- that women that have a pregnancy without breastfeeding, for example, those women are more likely to go on to develop diabetes years down the road. So I think as time goes on, we're recognizing this isn't so much about what's best for the baby, but what is best for the family.

Host Amber Smith: Do you have an estimate for what percent of women who give birth are choosing to breastfeed now, in 2023?

Jayne Charlamb, MD: The best tracking in the United States is done by the CDC (Centers for Disease Control and Prevention.) And their data that came out in 2022 showed us really a nice number of families start out breastfeeding their infants. Over 83% of infants born in the U.S. have been receiving some breast milk. Now that might be one day in the hospital. It might go on longer. And as we see, although the vast majority of babies start out receiving some breast milk, that number, that percentage goes down gradually. By the middle of the first year, only about 55% of babies will be getting any breast milk, and only about one in four babies will be exclusively breastfed at six months.

And as many of your listeners know, I'm sure, the American Academy of Pediatrics and the CDC both recommend exclusive breastfeeding for our infants to six months. So we're really meeting our goals, I think, at the beginning. But over time it wanes down. The number of families that are either wanting to or able to continue breastfeeding with a recommended amount at that six-month period.

Michele Dwyer, RN: Amber, I'd like to add -- not to belabor the pandemic -- but I personally, on the ground, saw many mothers who would not, and were not going to choose to breastfeed, choose to breastfeed because of the knowledge that they knew that they were passing along immunity and supporting that immune system in their baby.

Also, there was a (infant) formula scare and a shortage, and I had many mothers, and so I saw an influx, and I think our numbers will be higher just from that. A lot of mothers actually reevaluated how they were going to feed their baby, and that was a positive thing. So we ran with that in the breastfeeding medicine program and just capitalized on the fact that these mothers inherently knew and we just reinforced, "Yes, you're right. This is the way to feed your baby. It's the safest way.".

Jayne Charlamb, MD: I think Michele's right. We may see a nice tick up in the percentage, also because with the pandemic, many of us were home more, and there were opportunities for virtual work. So I think it made it be a cultural shift in the situation with moms and babies being in close proximity. A lot of the difficulties we see in families in the long-term breastfeeding, I think, are related to our culture and the separation that moms that are in the workforce faced.

So the pandemic, one of the silver linings, I think Michele is right, that our cultural shift was to keep moms and babies together longer.

Host Amber Smith: Do you know how breastfeeding in the U.S. compares with breastfeeding or formula usage elsewhere in the world?

Jayne Charlamb, MD: So it's very variable in the world. The U.S. Is pretty comparable to most Western countries. It's interesting when you look at other countries, one might expect, oh, the most advanced countries have higher breastfeeding rates. And that typically is not the case, because those same countries that we think are so wonderful and advanced and developed, they separate moms and babies. They don't necessarily have great maternity leave.

Very fortunately, we do have safe alternatives. We know our families have access to clean water and to regulated formula products. When you look at other countries, that's not the case.

Surprisingly, the country with the highest breastfeeding rate would be Croatia. There, they likely don't have alternatives. It's the cultural norm to breastfeed because that absolutely is the safest option, and for many families, the only option.

The lowest in the world is actually in Ireland.

Host Amber Smith: I will add that, personally, I think that in the United States we overthink breastfeeding. And as Dr. Charlamb had mentioned, I have had patients who come from other countries, and they don't understand why there is not more breastfeeding here. They don't understand how anyone can consider another form of nutrition for their baby. Upstate's "HealthLink on Air" has to take a short break, but please stay tuned for more of our discussion about breastfeeding.

Welcome back to Upstate's "HealthLink on Air." This is your host, Amber Smith. My guests are Dr. Jane Charlamb, who directs Upstate's breast health and breastfeeding medicine division, and Michele Dwyer, who is a nurse with more than 30 years' experience in maternal child healthcare. And before we get back to the interview, let me remind listeners that the number to call for lactation support is 315-464-MILK, or 6455.

Well, let me ask you a little about the history of breastfeeding, because before formula was developed, nursing was the only option, right?

Michele Dwyer, RN: That was the only option, and that's an excellent, excellent question because I will have mothers here in the lactation support center, and they are really anxious. They want this to work. They have a lot on their mind; they're just trying to get in the way of a successful breastfeeding relationship with their baby. And I bring them right back to the beginning, that civilization, as we know it, would not survive. We would be extinct by now if breastfeeding did not work. That was the only way, or else you died, that was it.

Jayne Charlamb, MD: So when I make it that stark for a mom, it's somehow easier for her because she now does have lots of support. It's not a life-and-death, situation. You have support that is available to you, we'll meet you at where your goals are because every family is different. In times in the past, certainly, and I think now, too, biologically, we estimate about one in 20, perhaps, about 5% of women are not able to -- for various reasons -- physically breastfeed their baby. Just as there are some women that have issues with infertility, there are some women that have issues with developing the milk supply. And I think we have ability now to support those families and fix some of the issues that they did not have thousands of years ago.

Before modern medicine, breastfeeding was the preferred choice of feeding infants, just as it is today. So in the past, what would've happened is you would get what we call a wet nurse. It would be another sometimes related, sometimes unrelated, woman who would breastfeed that baby. And this was very common. And if you look at Europe in the 18th century, and even in America, in the Colonial period, very common to hire a wet nurse who would potentially live with you. Or sometimes they would even send the infants out to live at the home of the wet nurse. And in Europe there was a huge demand for this service. And it wasn't just because women couldn't breastfeed. They would choose not to. They were thoughts that it wasn't good for her figure, or she was too busy with her social calendar. And so if you could afford it, you would hire a wet nurse, and the government in Europe actually regulated. There were laws mandating that the wet nurses have routine health examinations, and there were set guidelines.

This fell out of favor over the next couple hundred years and at that point sort of coincided with the development of infant formula. But it wasn't really until the early 19th century, or late 19th century, actually, that we had commercialized formula here in the U.S.

Host Amber Smith: Well, among the moms who breastfeed today, what are some of the most common difficulties? And how are they fixed?

Michele Dwyer, RN: Well, the most that I see now, it really comes down to the latch. I think there's a misconception that once the infant is born, you're just going to bring that baby to the breast, and it's all going to just all to work out.

It does, many times, all work out, and I don't see those mothers. But, many times it does not. There's pain. There's a little bit of fear. There's anxiety. There is worrying about your baby's weight. Am I feeding the baby enough? Can I just come in and get, like, a number? There's a lot of being wrapped up in the numbers, like the weight of the baby, am I making enough milk?

So what we do is, I always say that the easiest thing that I can do is to show the mother, yes, you do have enough milk, as far as the volume, as far as the number. Yes, your baby's weight is absolutely fine, and we talk about the number. But more importantly, what I try to do is to support the doubt. There's a lot of doubt. Am I doing it right?

Mothers will hear a conversation, regarding their baby and how much milk they're making, and they will take the negative parts. They will hear it in a negative fashion. "I'm not doing enough. I'm not making enough. My baby doesn't weigh enough. My baby's not as big as this baby over here."

So the majority, again, the details are easy for me to take care of. I can show them that everything is OK. Then the more extensive part of the visit will be to offer that emotional support. You can do it. You're doing a fantastic job. And I usually will not see a mother just once. It is a process. I'll see them two or three times in a month, in the early weeks of their infant, to get them through that one to four weeks of age for their baby, till they're really getting their sea legs, that they feel like, "OK, I think I can do this." And I will hear from them, which is so heartwarming to me, throughout the whole year. They will call me. "My baby's going to start eating complementary foods. How do I go about that?" "My baby wants to wean. My baby's 11 months old. How am I going to do that?"

So it's a relationship that we formed way in the beginning, and it is one of the highlights of my job, I will say that.

Jayne Charlamb, MD: Right now, the families having babies, when they themselves were born, breastfeeding was not as common, and so they were not raised seeing breastfeeding among their siblings, among their friends. And so I think what Michele provides is what would be naturally provided if we lived in a culture in which 98% of babies were breastfed. We would see our siblings, our cousins, our friends. Then we'd have a bunch of supportive women who have been there and experienced these problems surrounding our new families and helping them to breastfeed successfully.

And we don't have that established in our culture. Very often, the connection is just through Facebook to friends. A new mom may live thousands of miles from her family, may not have connections to other families who have successfully breastfed. So the basics of supporting a new young family really go back to personal support, and that's what our program strives to provide. And that's what Michele is so good at.

And there are medical issues as well. And so that's when I end up getting involved. But again, those are relatively rare. I'd say 90% of what comes to us on these phone lines is handled very quickly and very easily with some real basic support.

Host Amber Smith: Do moms who have twins and triplets, do they automatically have more of a challenge breastfeeding?

Michele Dwyer, RN: They do, just because of the sheer number. It can be overwhelming. And so I always say thank goodness we get nine months or so to realize that we are going to be breastfeeding two babies or three babies. But it's easily managed.

The beautiful thing regarding the lactating female -- her body will accommodate two or three babies. It can be extremely overwhelming. So that comes back to the support. But the female body is a beautiful mechanism, that it just will kick in. It will take a lot of time. But it is absolutely doable. And again, I'll say it again, it will take a lot of time.

And so that goes to the emotional part, to the mother and the family, the family as a whole, because we have a support person who is involved, who is very caring and doesn't want to see their wife or mother of their children getting exhausted. So there's a whole dynamic that does expand when there is more than one baby that you're trying to keep alive. But it can be done. It absolutely can be done. So we do like to offer that support.

Host Amber Smith: Well, the theme for this year's World Breastfeeding Week was "Let's make breastfeeding and work, work." So I'd like to talk about the difficulties, in 2023, for women in the U.S. Who want to breastfeed while working outside of the home. Are there things being done to help make that available as an option for women?

Michele Dwyer, RN: It is getting better, Amber. Much better. I have been doing this for over 30 years, and 30 years ago, not to be very specific, but I remember pumping in a bathroom, with a hand pump, and trying to get it done, so I could get back to work. And of course, I worked for maternal child, and I'm in the department of maternal child, and I had to cram it in to pump. And it was very stressful, very, very stressful.

But we have come, thankfully, a long way. We here at the breastfeeding medicine program, with Dr. Charlamb and other lactation support that is out in the community, have got together in recent years to advocate that businesses locally, because they legally have to provide a spot for a mother to pump where she's comfortable, and there will be privacy, and she is allotted time to do that so that we can support the breastfeeding.

So there are many rooms that I know of that have been incorporated into local businesses. We here at Upstate have them in almost every facility, actually every facility that I can think of now. And you have to have an electrical outlet. You have to have ... a sink would be nice, basic things, a chair, privacy.

So we have come a long way. We do have a little bit further to go. I know my teachers that are out there that go back to work, I would say they have the most difficult time. School systems try to find room, but I think space, there isn't a lot of it, from what I'm hearing in general. So they have a hard time. I would like for that not to be. And, again, in the restaurant, the customer service facet of employment. Those mothers have to fight very hard to continue to provide breast milk for their baby for a full year if that is what they want to do. We're getting better, but we have a little bit ways to go, to answer your question.

Jayne Charlamb, MD: You know, looking historically, I'm very proud of New York state. We were the first state in the United States to enact any legislation protecting breastfeeding. Back in 1984, they took breastfeeding and made an exemption from the public indecency offenses. And about a decade later, there was New York civil rights law giving a breastfeeding mom the right to breastfeed in any location she's otherwise able to be, private or public.

And more recently, like Michele alluded to, New York State labor law gives all employees in New York the right to express breast milk in the workplace, regardless of the size or the nature of their business.

But there are still challenges, especially in the industries Michele mentioned. I think the next place we need to go with this is to say, great, we now have the time when the lactating parent is separated from the baby. We're allowing pumping. But I think we need to start having a cultural shift looking more at longer parental leaves, because while it is great to be able to pump, it is not the same. And to expect a new parent six weeks after a delivery of a baby, to go back into the workforce and pump and come home and do laundry, and do diapers and do bottles is an awful lot. At that point, breastfeeding is just beginning to, you're just kind of getting your groove.

So my next push now that we're doing great with a pumping while at work, my next push will be to advocate for parental leave. And I think we in the United States are behind on that, frankly, when you look at the opportunities for being home with one's family after the delivery of a baby in the EU (European Union) and at various other countries, we're way behind.

Host Amber Smith: Well, I want to thank both of you for making time for this important discussion.

Jayne Charlamb, MD: It was great being here.

Michele Dwyer, RN: Thank you so much, Amber.

Host Amber Smith: My guests have been Dr. Jayne Charlamb -- she's an associate professor in internal medicine and obstetrics and gynecology at Upstate -- and nurse Michele Dwyer, who has more than 30 years experience in maternal child health care. Both are international board-certified lactation consultants. And the number to call with infant feeding issues is 315-464-MILK, or 6455. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate Medical University's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Kathleen Goldblatt is a poet who describes visiting her mother in assisted living. Here is "How I Take Care of My Mother."

I walk down the long hall to my mother's room

past dining tables, past cloned rooms,

to where she sits in her worn-blue lift chair,

bend to kiss the tissue-paper skin of her forehead.

We begin the game --

How are you? I'm fine. We're experts.

She wants everything tidy.

I straighten what I can, put away

pink flannel pajamas, clean the cup at her sink.

Drop into the empty wheelchair.

I ask about the chicken she had for lunch,

ask if I can turn on the television. Noise

fills holes. I want her to say no, act annoyed.

I want her to curse. An aide comes in and tells me

how nice my mother is. Niceness can be

a burden so heavy even Atlas wouldn't carry it,

I'm fine can be a conspiracy of lies.

She told me once how she climbed a tree

when she was young, how she refused to come down

for hours. Sometimes people hide so long

they forget they want to be found.

Pictures line her dresser, the window sill, a small table --

a family of skilled smilers. Tiredness creeps in,

I fix us both a cup of tea. I'm swimming across a lake

not sure there is another shore. I keep swimming

because she is old, because she won't come

down from a tree. I want to know if she is afraid

of death. I promise to come back tomorrow,

prop the door, say, I miss you. The only truth I tell.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," identifying and treating postpartum depression.

If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org.

Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Bill Broeckel. This is your host, Amber Smith, thanking you for listening.