Conquer Your Weight

Dr. Sarah Stombaugh: This is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight Podcast, episode number 63. 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 Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to today's episode. I'm so excited to have you here with me today. I am going to start by apologizing and saying I am so sorry we did not have an episode last week. Everything was good and ready to go, and I just had a quick thing to record and I got the worst laryngitis followed by a GI bug. Our household has been just totally miserable, so if you were wondering what happened to last week's episode, you're going to have it today. So thank you so much for your patience with that and I'm excited to share with you about GLP-1 and the medications like Zepbound, Wegovy Saxenda, those are the ones that are FDA branded for the treatment of obesity. But even the ones that are branded for the treatment of type 2 diabetes like Mounjaro and Ozempic, we know that these medications can be very, very effective and sometimes people are not using them appropriately or are not following the right diet. They don't really know what should I be eating when I am on these medications. So we are going to talk about that today. So if you have been prescribed these medications and you haven't gotten a lot of advice, especially if you're feeling like, oh my gosh, I am not hungry at all, is it okay to just not eat anything? Is there a certain minimum I need to be eating? Are there goals that I should be looking towards? I am going to provide you with some general guidance today. What I will say is that, dear listener, I am not your doctor. And so you do need to take into consideration if there are specific dietary concerns that you have been advised by your healthcare team to follow. And if you have any questions, if this podcast raises some interesting points and you want to run it by your own doctor, please do do that because I want to make sure that you are getting the advice that is going to be right for you and not just for a generic person. So with that said, let's talk a little bit about these medications and what types of foods, supplementations, et cetera, that we should be taking when we are using them. So this group of medications we have talked about before, the GLP-1 receptor agonists are medications that support our body both within the brain as well as within the GI system in order to reduce insulin resistance and promote weight loss. And we know that they can be very, very, very effective. Some of the medications like Wegovy for example, can produce about 15% total body weight loss on average, where Zepbound the newer kid on the block can produce 21% total body weight loss on average. And then in some of the studies where they combined the highest dose of medication also with intensive lifestyle intervention, the average patient lost 26.6% of their total body weight loss and of their total body weight rather. And I just want to say that is really profound and that is just the average. So if you look at a chart, there's a really broad distribution, people who lost very little weight and the people who were even approaching 50% of their total body weight loss. And so when we are having that significant of weight loss, we really need to be cognizant of what is happening and how we are supporting the body in a way that is going to promote losing fat mass and maintaining as much of our muscle mass as possible. The other thing to think about is with these numbers, we are actually starting to approach the territory of bariatric surgery. So we know that bariatric surgery will often produce 30, 35%, 40% total body weight loss. And so for some people on these medications, we are finding that these can be comparable to bariatric surgery. So we need to make sure that we are getting adequate nutrition so that we are not malnourished alongside our weight loss. We talk sort of casually about weight loss, but the reality is I don't want you to lose just weight, I want you to lose fat mass. And that sounds like a funny distinction, but one of the things that happens when we lose weight, we tend to lose both fat as well as some of our lean muscle mass and some of that is to be expected. If you imagine a 300 pound body, for example, and you think about the amount of muscle required to move a 300 pound body through space, that is going to require a certain amount of muscle. Let's say that person loses 100 pounds and now weighs 200 pounds, there is simply less muscle required to move that 200 pound body through space compared to that 300 pound body. If you imagine carrying a hundred pounds and taking that up the stairs with you and taking that when you're on a walk with your family or taking that to the gym, any single activity that you do that is going to build your muscle because you're simply moving that weight through time over and over and over again. So there may be this proportionally decrease in muscle mass when we lose weight and there's nothing necessarily wrong with that. But what we need to be really careful of is that when are losing weight, we are doing everything possible in order to support the muscle mass that we need so that we don't lose it disproportionately. And when these medications that are so effective when they are taken not with the adequate dietary guidance or supplementation guidance, people can have issues where they start to lose more muscle mass than is healthy for them. And in the short term, that may not create an issue. But what happens in the long term is it can create problems with sarcopenia, which is a condition where we have not enough muscle mass for our body, it can start to draw it because of the less muscle pulling on our bones, it can start to draw energy from the bones causing things like osteoporosis, osteopenia where we have a decreased bone density. So even though a number on the scale looks better, we are actually creating an overall worse health state for people when they disproportionately lose muscle mass. So the most important thing I want you to know is that I want you to protect your muscle mass really regardless, but especially if you're on these medications to make sure that you are protecting your muscle mass alongside your weight loss. So what that looks like is making sure that we get enough protein and that we get adequate number of calories in order to support our body's metabolism. So when I say that we know that weight loss comes from caloric deficit when our body has is taking in less calories than it needs in order to function, we reach to our fat stores in order to burn those for energy and then we start to see weight loss. So we do have to be in a caloric deficit. And what happens is that these medications produce a state where it is much, much, much easier for us to be in that caloric deficit. They decrease some of the food chatter in our brain, they decrease the movement of food in our GI system. So food stays in the stomach longer, it goes through our intestines and our bowels for a longer period of time, and what happens is that we are able then to eat less energy and we feel less hungry. So some people notice it as a mild decrease in their hunger. Some people notice it as a much more extreme decrease in their hunger or they're like, yeah, I just really feel like I don't have to eat at all. And that is in some ways that's good, but in other ways that may be a little bit of extreme and we need to make sure that they are actually eating and supporting their body. So what does that look like in general, I want to make sure that people are having adequate calories that are going to meet their metabolic needs. Certainly I want someone to be eating at least 800 calories per day, but that would be a sort of a bare minimum. We want to make sure that they are eating enough calories to be in a deficit and enough calories to fuel their body. So that made me eating throughout the day, breakfast, lunch, dinner. But it may mean you wake up in the morning and you're like, gosh, I'm really not that hungry. I know I need to eat something, what should I eat? And so I'm encouraging people to eat protein consistently throughout the day in order to support their muscles and make sure that they have enough energy to use and help to use that both for energy as well as for building and maintaining that muscle mass. So the reason that we lose muscle mass when we are losing weight is that if we do not have adequate energy coming into our mouth, our body starts to look for energy sources within our body. So we think about depleting those from our fat stores. We can also take that energy from our muscle stores. So in order to prevent that, we need to make sure that we're having adequate protein. Now this is the question. You'll hear so many different numbers that are quoted here, but what is the adequate amount of protein that you need to have? A general rule of thumb is about 0.8 to 1.2 grams per kilogram of protein per day. But for some people on specific diet plans, they may actually be having two grams per kilogram of body weight and that translates to about a gram per pound of body weight depending on the person. We are also thinking about what is both their body weight now and what is their ideal body weight. And so a lot of times we'll be using that also based on their ideal body weight because I will tell you there is nobody who should be getting 300 grams of protein per day. Even my husband who is a power lifter gets nowhere near that. So if you feel like you were eating 300 grams of protein per day, that is simply too much and you need to make sure you're talking to your doctor about what your goal should be. For the average person, let's say that someone weighs 220 pounds, I use that number because that is about 100 kilograms and that would correspond to then about a hundred grams of protein per day. So as a sort of general estimate for people, I like to set that 100 grams per day as the minimum. It may be a little bit higher depending on the person and depending on their specific exercise routine, on their specific body weight, but sort of a minimum of 100 grams of protein per day for patients who are trying to lose weight, what that looks like is making sure to get it through food and or supplementation sources. Either of them are fine. So that can mean getting things like meat that can be in certain dairy products, in whole grains, in fish, in soy products, in legumes, we're getting it in lots of different sources. We can also get it through supplementation. Things like protein drinks, protein, water, bone broths are a really great way in order to get it. And so you can do, and most people do a combination of those two things in order to meet their protein needs, especially if you are not feeling hungry. What I often recommend is to make sure that you are having protein shakes at a period of time where you would typically be eating a meal. So if it's lunch and you're like, oh my gosh, I really not super hungry right now, I know I should be doing something that is an excellent time to have a protein shake or a protein bar or something like that. If you can pair it with a real food, something that is really fiber forward, that can be helpful in terms of your overall digestion, making sure that we protect your gut health, but do emphasize getting that protein throughout the day. The interesting thing, our body has really good storage in terms of storing carbohydrates, in terms of storing fat. What we do not have is really good storage for our protein. And so when we don't have the protein which is broken down into amino acids, when we don't have those readily available for use, what our body does is get those from our muscles. And so making sure that we do have this sort of regular drip of protein that is coming into our bodies is an important thing to help support those muscles as well. So protein, protein, protein. I'm constantly talking to my patients about protein. The other thing is just sort of nutrients in general. So when our appetite is so suppressed, we may not have the same room in our stomach to eat the meals that we typically would have eaten before. So what we need to make sure that we are doing is choosing foods that are really nutrient dense first. So what that means is our protein foods and really any vegetables and possibly some fruits as well. So we want to be choosing those foods that are going to give us both our important macronutrients as well as some of our micronutrients. So these are things like our vitamins and our minerals. We know that having fiber is important, so vegetables are really an excellent way to both get fiber, not get a huge sugar load, and then to make sure that you're getting those vitamins and minerals. I also recommend for all of my patients who are taking these GLP-1 medications, whether it's set bound, whether it's wegovy, that they are also taking a multivitamin to be honest, any old multivitamin will do, but when we start thinking about bariatric surgery, when we start looking at what are the things that bariatric surgery programs do in order to support their patients when they know that they're going to have these really significant weight loss, we know that they are recommended deep protein and to make sure that they have a bariatric multivitamin. And so there's really no reason that that should be any different when we are losing weight in this way, there's not the malabsorptive effect. So one of the ways in which bariatric surgery can promote weight loss is some of those surgeries will create a malabsorption. So we certainly could have even more issues with getting our micronutrients, but the reality is it is okay to take just a regular multivitamin to make sure that we are adequately getting those even if there's not going to be a malabsorption. The other thing I've been alluding to fiber, a lot of us do not get enough fiber in our diet. We need at least 25 to 30 grams of fiber per day. The best way to get fiber is in the form of whole fruits and whole vegetables, so especially vegetables that are going to be not starchy. So they're very low calorie thinking about broccoli and cauliflower and lettuces and green beans and peppers and things that are not going to create a lot of sugar and a lot of starch that can cause that glucose response. But things that are going to be just really fiber rich without a lot of calories, that plays such an important role in our GI health in order to promote good soft, bulky bowel movements. Now, it can be challenging when you're not feeling particularly hungry, not feeling like eating huge volumes. So one of the things that I often do is supplement my patients with fiber. Also, I really like Metamucil, but the thing that you have to be careful with is that standard Metamucil has a lot of sugar in it. So if you're using Metamucil, you should either use the Sugar-free version or you should take the Metamucil capsules. I personally am not a huge fan of the flavor of mixing the powder into a big glass of water. I know some people who actually really enjoy that. So if you like it, by all means do that. I think that I just sometimes influence people because I do not like the flavor of that, so I tend to refer the capsules. The problem with the capsules is that you have to take a lot of them to really make the same amount of fiber, but taking those kind of building it up, starting low, building those up slowly, I often will have people taking those throughout the day in order to make sure, especially if they're not getting a fiber with a meal to make sure that they're supplementing it, that helps to also slow down our digestion, provide that bulk in our stool, and that can also help to mitigate some of the side effects that we can commonly see on these medications. The other thing is simply making sure we get enough hydration, the urge to drink as well as the urge to eat, go really closely hand in hand. And so it's common that people on these medications feel less of that urge to drink. So just be aware of, okay, even if I'm not thirsty, have I dranken, I can't talk, have I had, we'll just say, have I had enough water today? And if not, making sure that you're getting throughout the day. Sometimes things like protein waters or protein shakes or broths, give me an excellent way to get both water as well as protein. So that may be something to consider. And I have a lot of patients who do that. The other thing to think about is how are you treating your side effects? We've talked a little bit about the constipation, but one of the things that can happen with these medications is nausea. And having recently had a GI bug myself, we often, when we are feeling nauseated, we'll often turn towards things like crackers or ginger ale, foods that are really sugar forward and feel easy for our bodies to digest. And that may be fine in the context of a GI illness, especially if you've been getting really sick, your body may need some of that may feel really gentle and easy. But when you are on a medication, if it's producing a little bit of nausea for you and you feel that week in and week out after your injection, and if you are someone who turns towards ginger ale and saltine crackers and that type of thing, you can actually be really causing maybe not harm, but preventing yourself from having the success that you would otherwise have had. So finding ways that can help you to manage nausea that are not crackers, that are not soda is really important. So really cold beverages can often help with nausea. Citrus can help with nausea. So like a really cold lemony drink, for example. Peppermint can help with nausea, ginger, even not in the form of ginger ale, but ginger tablets or ginger tea. That can be something that is a bag of tea. Or even buying a ginger root and grinding it or slicing it thinly and brewing that in hot water can be really helpful. And then drinking protein actually can help to support that feeling of sort of something sitting in the stomach when you feel kind of queasy and like, Ooh, I don't know what sounds good. Sometimes having protein or a broth there can feel really nice as well. So if you were someone who's experiencing nausea from these medications, just make sure that you are allowing yourself to be benefited from that and not to take in a lot of excess sugar in that way. So one of the things any of my patients will tell you is that I really don't like to push the titration of these medications. All of these are designed to start low and kind of gradually increase up, and we start at the low dose. The quickest that we would bring someone up is every four weeks based on what their side effects look like, based on what their weight looks like. And it's interesting because in all the studies, as long as someone wasn't having just miserable side effects from it, they sort of push that next titration. So it's like, okay, you start the low dose, okay, four weeks later you're in the second dose and then four weeks later you're on the third dose and four weeks later you're on the fourth dose and sort of pushing people up to this maximum dose. We especially saw that on Wegovy, not as much on the Zepbound, but even there just somewhat. And my practice style is that I do not push the titration of these medications. I want to use a dose that is going to help support people in their goals, help them to produce an adequate body weight loss, but not just have huge amount of weight fall off where they are not adequately able to support their lean muscle mass. And so too fast rate of weight loss can cause other issues too. We start to see hair falling out. Maybe we're feeling weak, feeling weak, we don't have a lot of energy. And so there's this really fine balance of how do we support people, make sure that they have this good continuous rate of weight loss while also not pushing them too quickly and causing other issues. So I've thrown a lot of different interesting information at you. The reality is everybody's body is going to be different. How we process these meds, do we have side effects? I'm always talking about side effects. And the interesting thing is I have patients who have almost no side effects and they're like, Dr. Stombaugh, I thought I was going to be totally miserable from the way that you described it. And I'm like, well, it's that difference between what is our expectation and what is our reality. And so I set that expectation of you were likely to have side effects, but I have some patients who don't have any, they feel really good while they're on these medications and they feel like the medications help to support their goals, have less of that food noise. And so that is excellent, but it is common that people have just really decreased appetite. And so we need to make sure that you can lean into that and get the support that can come get the weight loss. That can come from being in a significant calorie deficit while also making sure to have enough protein, enough micronutrients, and simply just enough energy to also fuel your body. So if you have questions, if you were in the state of Illinois or Virginia where I am licensed to practice medicine, I would love to see you as a patient in my practice. If you are elsewhere and you feel like you don't know where to turn, please reach out. I love to connect with people, help to connect them with a physician who is in their area. So please let me know how we can support you With that, thank you so much for joining me today. I will see you all next week. Bye-Bye.