Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the long-term. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and to sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today’s episode. This is Dr. Sarah Stambaugh, and you are listening to the Conquer Your Weight Podcast. Announcer: Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stambaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to today's episode of the Conquer Your Weight podcast. We are going to be talking about what happens if you stop your GLP medication and can you stop your GLP medication? How do you wean off your GLP medication if you desire to do that? Because this is a question that we get asked probably every single day, if not multiple times per day. There's a lot of conversation around short-term use of these medications versus long-term use of these medications. And it's really challenging because the answer to this question, can I stop my GLP is going to be, it depends. And that is such a frustrating answer because what does it depend on? That is what we are going to talk about today. And what we've seen in terms of clinical trials, in using medications, in discontinuing medications, what has happened as we've had more experience with these medications. I'll share some new studies that have been done, as well as some of the experience from my practice and from many of my colleagues. So let's talk about what happens if you stop your GLP medication. Can you stop your GLP medication? Now, the question that I will always ask to people is trying to understand why is that their goal? You know, a lot of times we talk about obesity bias as our society, as an internalized thing. A lot of times there is this belief system, again, both in our society that we have adapted as individuals and adopted into our own belief systems to say, okay, that's been so pervasive for so many years. A lot of times when we're seeking help, we feel like maybe we failed if we're deciding to use a medication or to use something like bariatric surgery. If we're using that in support of our goals, it feels like a failure. It feels like some sort of moral failing that we haven't been able to do this on our own. But the reality is our weight is driven by so many factors and our metabolic health needs. Many of those factors are determined by things like genetics, by other health conditions, by the environment in which we live. And while there's a lot of things that we can do to improve those and to adjust those, some of those are outside of our control. And so there's this messaging around just needing to work harder, to eat less, to move more. And so a lot of times in choosing to move forward with a medication, the decision to do it is like, well, maybe I'll just do it for a temporary amount of time. So let's talk about that. How do we decide starting the medication, what that journey looks like, and then what happens if you stop? So in starting the medication, I think one thing that's really interesting is that in the clinical trials, both for Wegovy and Zepbound medications, so Wegovy is semaglutide. That's the same medication as Ozempic. Zepbound is tirzepatide. That's the same medication as Mounjaro. And one of the things that's been really interesting is that in the clinical trials for those medications, patients were titrated up pretty quickly to the next dose of medication. So patients were started on the lowest dose of medication. And then every four weeks, as long as they were doing okay on that dose, they were moved to the next dose. And when I say as long as they were doing okay, I mean, they weren't like vomiting their brains out having severe side effects. It didn't have to do with if they were achieving their weight loss goals or anything like that. Patients were moved to the next dose of medication. And in the Wegovy trials, patients were uniformly moved up to the 1.7 or 2.4 milligram dose. Those are the top two doses of Wegovy. In Zepbound, they did study three different doses of medication, the 5 milligram dose, the 10 milligram dose, and the 15 milligram dose, and studied patients on those over the period of, depending on the study, a year or a little bit over a year. And what was really interesting though, is that what we see in clinical practice is that an individual's response to medication can be really unique. And so one thing that I do in my practice and many other physicians do as well is that we start patients on low doses and then, well, everybody should start at a low dose unless you're switching from another medication. It doesn't matter your body size. It doesn't matter your gender. It doesn't matter your disease process. Everybody should start at a low dose of medication. And then depending on what your response is to that dose of medication, that you can actually stay on that dose of medication for as long as it is supporting your goals. And so it is very common in my practice that we have patients on doses like 2.5 milligrams of Zepbound, which is the starting dose of Zepbound. And they may be on that for a long period of time. Maybe they're transitioning to to five milligrams, but we absolutely have patients who will take these low or low intermediate doses and stay on them for long periods of time and have phenomenal results. And so we look at how is your body responding, both in terms of the side effects of the medication, as well as then in terms of effectiveness of the medication. And if you're on a certain dose and the effectiveness seems to not be as significant, you're not losing the same rate of body weight, that's when we consider, okay, is it time to make this adjustment upwards rather than just sort of every four weeks making that adjustment? And the reason why this is important is that one of the things we've seen in small retrospective studies, meaning they've looked at people sort of after the fact, people who've been on lower doses of the medication come off of the medication more easily compared to someone who was in a much higher dose of medication. And so why over-treat someone if a lower dose of medication is adequately supporting them? So this microdosing, which we've talked about a little bit before, but not even microdosing, just using what is the smallest dose that's effective for the patient and then moving upwards if we need to can be really valuable. I do have patients also who are taking semaglutide products and things like Ozempic were able to give partial doses of medication. So I have patients who take doses like 0.5 or one milligram, these sort of half doses of or fraction of a doses of medication that can be really supportive also in long-term weight loss goals, even if they haven't moved up to that top dose of medication. And so there's nothing wrong or bad or different about any one dose. It's going to be, what is the dose that's helping you to achieve your goals? So we start low and then we see, okay, is it feeling good in your body? Are you able to still nourish your body with some food, right? The goal of this medication is not don't eat anything. The goal of this medication is to decrease appetite, to increase fullness, to to decrease cravings of certain foods such that you're allowed to make the food choices that are in line with your goals that you're able to emphasize protein emphasize fiber And then all of the things you've been trying to do for all those years, that now they're finally able to take effect because you fix the underlying metabolic piece. And so we started a low dose. We look at how is it feeling? How is it supporting your weight loss goals? And as long as you're continuing to lose weight, great. We stay on that dose. If we find that things are slowing down or you're hitting a plateau, that's when we look to reevaluate certainly other pieces as well with nutrition, with movement, with sleep conditions or other health conditions. But that's when we're thinking about, hey, do we need to move up in the dose? And then if someone is achieving their weight loss goals, this can look like a lot of different things. Some people's bodies will plateau at numbers before they've reached their goals. Other people, their bodies are still continuing to lose weight beyond their goals. And so we look at how they are responding to medication. And sometimes it's the case where we almost need to wean someone off of medication. I've had patients for whom they are on a dose of medication and they're losing and they're losing and they're losing and their body mass index, for example, has dropped from 35 to 30 to 25 to 20. and now it's like, oh gosh, we're still going. They're still losing weight. And is that really necessary for them to continue to do so? You know, absolutely not. And so the idea of taking a step back on the dose makes a lot of sense. So when we think about, we start slow, we titrate based on someone's response, and then the decision of what happens from there is also going to be very individualized. Now, what's really interesting is is that both for the semaglutide products like Wegovy and for the tirzepatide products like Zepbound, there are clinical trials to say what happens if you stop the medication. So again, these are patients put into clinical trials. They were started with the medication. They were moved up on the dose every four weeks to the top dose of medication, and then they were discontinued. And half of the group discontinues, half of the group continues. Nobody knows which arm they're in. Are they taking the medication? Are they taking a placebo? They have no idea. But everybody starts on the medication, then they either continue or switch to taking a placebo. So discontinuing the medication and then seeing what happens and what happens on average, it depends on the medication. But on average, people will have weight regain a lot of times about half or a little bit more, up to three quarters of their body weight may be regained. And then if you look at what's called a waterfall distribution, where you're not just looking at the average person, there's a really broad variation of people who regained all of the weight that they had lost plus more. So they actually now at the end of the clinical trial have more body weight compared to when they started, but then also patients who even after discontinuing the medication actually were able to maintain their weight pretty readily. And so that comes down to some individual factors. So when we think about what are those individual factors, what are the pieces that are predictive of someone who will maybe respond well at a low dose of medication, someone who may not need the medication long-term, what does that look like? The factors that are going to be most predictive is how much underlying metabolic disease do you have? So that will be things like full-blown, do you have type 2 diabetes. Do you have prediabetes? How long have you had? Do you have elevated blood sugars? How long have you had those things? When you look at the excess weight on your body, how much excess weight do you have? And for what period of time have you had that weight? The story of someone who's had excess weight for five years may look very different compared to someone who has struggled with their weight for many decades, for example. And so when we look at the responsiveness to medication and what may happen long-term, the people who are more likely to respond to low doses and then potentially wean off of medications are people for whom have not had chronic underlying metabolic disease. So they do not have as significant of metabolic disease like prediabetes or type two diabetes. When we look at their metabolic disease, it's mild presenting as early signs of weight gain, and they may have a smaller amount of weight, like 20 to 50 pounds that they've had on their bodies for shorter periods of time. Now, of course, that is also just a generalization, but those are some factors that may be predictive. Now, one thing that was really interesting was that in Denmark, they did a study looking at what happened when people took sort of customized or as low of a dose of medication as possible. And then what if they tapered off of their medication? Now, I will say all of the interesting semaglutide studies are coming out of Denmark. If you don't know the company that makes semaglutide, so Ozempic and Wegovy is Novo Nordisk. They are based out of Denmark and these medications have actually changed the country. It's completely changed the GDP of the country. So much of the country's money is coming from Novo Nordisk being from these companies. And so Denmark has been doing all sorts of really interesting studies with the semaglutide medication. This one was presented a little over a year ago in the spring of 2024 in the European Congress of Obesity. And what they were studying is what happens if you, they called it microdose, but use a low dose or customized dose of medication. So everybody started at 0.25, which is the traditional starting dose of medication. And then they were only moved up if they achieved less than 0.5% or less of their weight loss goals per week. And so if they were losing or less than 0.5% of their body weight per week, and on average, patients were titrated up on their dose to an average of 0.77 milligrams. So with the semaglutide medications, Ozempic and Wegovy, that goes all the way up to 2.4 milligrams at the maximum dose. And so 0.77 milligrams is really about a third of I'm trying to do some quick math of that, maybe a little bit less, but about a third of the maximum dose of medication. So patients are still in this study in general, taking a fraction of the dose, but they're trying to provide that customized response. Now, what's interesting is they had over 2000 people in this clinical trial and they offered to patients to taper off of the medication. And so 353 of the patients did decide to taper off of medication. So it's not a huge amount of patients that we're talking about here, about 15 of the patients in that clinical trial were decided to taper and 240 of the 350 did successfully taper off to zero medication. What's really interesting is that those patients on average, not only maintained their weight, but continued to lose an additional 1.5% of their total body weight. an additional weight loss from the time that they started their wean until they came off of the medication. And so that's pretty cool. Actually, I'm saying that wrong. They discontinued the medication and then 26 weeks after being off the medication, they had maintained or lost an additional 1.5% of their additional body weight. And so on average, the patients who did wean were able to wean and stay off the medication successfully. The thing I think that's really interesting there. And the study doesn't go into talking about what were the factors that they used to determine who those patients were. So who were the 353 who even attempted tapering, for example? And then what were the factors that differentiated the 240 who did indeed taper off of their medications versus the 110, 113 patients who did not actually successfully wean all the way off of their medications? What were the difference between those groups. And then what's really interesting is that even in that 240 patients who weaned off of medication, there were some of whom went back on the medication. So 46 of those 240 went back on medication. And I feel like even as I'm saying this, we're getting like super numerical here, but let's talk about just sort of on average. So 15% of the patients did attempt a taper. Of those people who were attempting a taper, about two thirds of those patients did taper off completely. And then most of them, so about 200 of them, stayed off the medication, did fine at 26 weeks after the study, had maintained or lost additional weight, and then 46 of those patients, so of the 240, almost 200 stayed off of the medication, 46 went back on the medication. And it's easy to imagine the people who may have restarted the medication and what that would have looked like. One of the things that I see in my clinical practice is that we have this idea starting out that I don't want to take a medication long term. I'd like to stop this medication. I'd like to use this medication temporarily. And I believe very strongly that you as a patient, you are the boss of your body. You know your body best. You get to make the decisions about what you are or are not putting in your body. I will provide you with the medical advice. I will provide you with my recommendations. But if you don't want to take something, I certainly... There's no way I can even force you to do that, but I would absolutely never even encourage or twist somebody's arm that like, oh my gosh, you have to continue taking this thing. You are the boss of your body. Anything you want to stop, I will support completely and I will help you come up with a safe weaning plan when that is the case. And so... it's very common starting out that people ask me this question, can I stop? What does it look like to wean off? And I'm always open to that happening. What I have found in clinical practice is that many people who are interested in using the medication in a temporary fashion find that having the medication in their body feels simply amazing. Many of them have been struggling with significant food cravings, with food noise, just thinking about food over and over and over again. And it's really challenging to be in this position where your brain is just constantly focused and hyper-focused on food choices. And they find that using the GLP medication quiets that down for the first time in a way that they are able to eat the foods that they've been desiring to eat, to eat protein, to eat fibers, to maybe intentionally incorporate in a sweet treat. But when they do have it, that you can choose a portion that aligns with your goals rather than feeling like, oh my gosh, it's always calling to me from the kitchen or as soon as I have one bite of it, I just want to have the entire thing or have the entire cake or whatever that looks like. And so... the effect of this medication on that system, on those cravings, on those urges is profound. It's really life-changing for a lot of people. I also have a lot of patients for whom, whether they're dealing with official binge eating disorder, maybe they're dealing with a lot of cravings for alcohol, this medication also turns down cravings for alcohol. And so it's been really interesting for a lot of my patients that they're finding this freedom around both alcohol, around sweets that they had never had previously. And once they experience the medication, their perspective of it changes in a really significant way. And so many patients start the medication, they're using it for a while. And even as they're hitting their goal weight, we may be looking at things like Do we just stay on a maintenance dose of medication if they are losing beyond what we would want them to? Do we have them take a lower dose of medication or perhaps space out the dose of medication? That may happen, but it comes down to these very individual factors. How does it feel to have the medication in your body? How does it feel to have the medication out of your body once you've experienced that, once you've been able to make those? Is it something that you want to continue with versus realizing, oh my gosh, now that I'm using this medication. It's supporting my goals in a way that I could have never imagined. I think that's one of the things that ends up surprising my patients the most is that all of these years they have been on diet plans in the past. They've been working on their nutrition, working on the behavior goals, working on their movement and feeling like there's so much mind drama. There's so much, so many thoughts about food and cravings and urges and just feeling like their body is fighting them that using the GLP medications, whether that's Wegovy products like, you know, the semaglutide products like Wegovy, the tirzepatide products like Zepbound, that all of a sudden they just find this freedom that was never there before. And so when we think about discontinuing the medication, this is what I want us to think about. How do we support patients in their individualized goals? How do we make sure that we're not unnecessarily rushing them up on their dose of medication, that we are allowing them to make the food choices, getting protein, getting fiber that are going to support them, that we're thinking about other pieces of their health picture, things like sleep, things like other health conditions or medications for those that may also be driving weight, thinking about the types of movement we do, just movement in general, as well as resistance training, things that are going to build our muscle, help support our metabolism. All of those factors are going to be really important. And then as we're achieving our weight loss goals, we get to decide, do we continue the medication? Would you like to trial a lower dose of medication? It's very common, as I said, that I have patients who do decide to stay on the medication, but may be able to come back to a lower dose or do it less frequently. And all of those things are absolutely options. What I will recommend to you is that if you're wondering about these medications, maybe you're even taking them and thinking, could I stop it? Would I want to stop it? How would I do that? Working with a board-certified obesity medicine physician is going to be the best thing you can do in order to support those goals. You can find a board-certified obesity medicine physician at the ABOM, the American Board of Obesity Medicine, and you can use their provider fighter tool to find someone who is close to you. If you are in Illinois, Virginia, or Tennessee, where I am licensed to practice medicine, I would love to have you as a patient in my clinic, you can reach out to me at www.sarahstombaumd.com. We'll put all of that information in the show notes. You can click on over there. Thank you so much for joining us today's episode. We'll see you all next time. Bye-bye.