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 longterm. 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 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 Stombaugh 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 Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this episode of the Conquer Your Weight podcast. I'm doing something pretty exciting today that was a little bit spur of the moment. As you have heard, I have launched The GLP Guide, which is my new online resource for patients who are taking GLP medications and looking for a little bit more support, understanding nutrition recommendations, how to manage their side effects, what to do when they're traveling with medications. What if they missed a dose, what if they took too much? We have answers to all of the most common questions and to celebrate. We had a lunch party yesterday on Tuesday, October the first and did a live webinar, but it was so, so good. What I decided is that we will take the recording from that webinar and share it in the podcast. And so that is exactly what we are going to do. Take a listen for the webinar that we did, the GLP Q and A and enjoy. Let's go ahead and get started. And I would like to talk about what everybody should know before starting a GLP medication. And there are certainly people in this call who are already taking GLP medications and that is okay, any of these things that they will still apply to you and things that you can still implement regardless of where you are at in your GLP journey. So one of the things I want to point out is that we talk about the GLP medications, we talk about this class of medications and it's actually pretty broad class of medications. This group of medications was initially used for the treatment of type two diabetes and we've been using them as such for really about two decades now. So we've got a lot of great safety data for these medications. And then over the last few years we've seen them also receive FDA approval for the treatment of obesity. And there are many different medications in this category. Typically when we're thinking of them from a medical weight loss standpoint, we're thinking about the ones that are FDA branded for that purpose. So Wegovy is the semaglutide product that is FDA branded for the treatment of weight loss, the Wegovy medication, semaglutide and Ozempic. All three of those things are the same. They are referring to Ozempic is the diabetes version, Wegovy is the version for medical weight loss. And then semaglutide is the version that is a generic or typically compounded version of that medication. There's also a version of the medication or a different GLP medication called Zepbound, mounjaro, or tirzepatide. Zepbound is the medication that is FDA branded for the treatment of medical weight loss. Mounjaro is FDA branded for the treatment of type two diabetes. And then tirzepatide is that generic version. Typically that is going to be a compounded version. So in the talk today, I will be primarily using the names Wegovy and Zepbound, but that will refer to either any of the semaglutide or Ozempic products when I say Wegovy and then with Zepbound, also referring to Mounjaro and tirzepatide. So when you were starting these medications, I think one of the things that's most important to recognize is that the response to the medication can be really variable. And what is important with that is recognizing that we see these medications are very popular. Maybe we have friends or family members who are taking them. We see influencers on social media or just people on social media who are sharing their journey. And it can be really intimidating because while we can get a lot of information from other people, our bodies are unique and individual and we cannot necessarily take what is happening to someone else and apply that directly to our journey. So recognizing that there is a part of this, of what is happening with me, what is happening with my body, how am I feeling, what are my side effects and how do I best support myself in this weight loss journey? Now in the GLP guide, we have a lot of different videos who are addressing some of these different things, but part of it is also a little bit of trial and error in terms of what is going to improve my side effects. Maybe there's a day of the week that's better for me. Am I going to be more responsive to Wegovy or Zepbound for example? These are both great medications, but there are people who are more responsive to one than the other. And so sometimes we do need to make adjustments. And so I think sharing that to say it is so important to give yourself grace in this journey. So important to recognize that your body is unique, it will have its own response. And then how do we make adaptations to best support you? So let's talk about a little what that looks like. I often have patients who fall into two categories, patients, well, maybe even three categories, but patients who come and are really excited about medications and at the very first visit they're like, Hey, I'm totally ready. I want to start a medication. There are patients who are like, maybe I want to start this medication, let's get started and then I'll see if it's something I want to add on later. And then I have patients who are adamantly opposed. But for the patients who are considering medications, the ones who are gungho about it and the ones who are like, you know what, I want to take a little bit of time and then decide over the next couple of months if it's something that I should start. The great news is that when we are able to implement certain nutrition changes, start paying attention to our lifestyle, what is supporting us that can really make a huge difference in how successful we are in our weight loss journey and how much one weight we're able to lose. But then two, how good do we feel in terms of side effects and all of that while we are in our weight loss journey? So it's really interesting. There are studies that say patients who are enrolled in an intensive lifestyle intervention program. So that is a program that includes nutrition advice, that includes exercise recommendations, that is providing coaching support for patients to be able to implement changes in their life when they are doing that alongside using the medications that they have, much less side effects and much more effect when it comes to weight loss, which is really phenomenal news. And so patients who are taking these medications and not necessarily making other changes alongside of it, they are not going to have the same results as someone who is really sort of going all in. And so I will say to any haters out there, I know there's none on this call, but for people who are like, man, is it cheating? Is it okay to use these medications? Absolutely. I mean, we know that when you pair these medications with that lifestyle intervention, with nutrition, with exercise, with coaching to support, how do we implement these things into our lives that it makes a huge difference. And these medications are what allow our physiology to change and adapt so that we are able to finally, all those things that we've been trying to do for all those years that they finally, finally work for us. But our response is variable. And so recognizing I'm an individual and I'm going to have to sort of work with my body here. Now, there are some really good principles that we can apply to anybody who is using these medications. So let's talk about things that while you're taking a GLP medication, you want to make sure that you are focused on so that you can be most in aligned with your weight loss goals. Now the first I want to point out is protein. So you'll hear this all over the place, protein, protein, protein, and the reality is protein is really important. The reason why protein is so important is that it one helps to create satiety. It can provide bulk that makes us feel full and stay full for longer. But more importantly, our protein intake helps to support our muscle mass. Now, when we eat protein, it's broken down into amino acids and those are used as building blocks of our cells, of enzymes, of hormones. They're used in many, many different functions in our bodies. They're also used to build our muscles. Now, our body does not have a great storage mechanism for protein. If we eat too many carbohydrates, our body can store that away as fat for later. Our body eats too much fat. We can use that as energy for later. But when we eat too many proteins, our body just metabolizes that for energy and can, it doesn't store away actual protein. There's no option for us to do that. But when our body needs protein, when it needs to be making cells, making enzymes, making hormones, doing these things, if you're not getting adequate protein in your diet, your body will start looking at your muscles as a source of protein and start breaking that down in order to fuel the other protein needs of the body. So especially during the weight loss journey, while we're often in this colorectal deficit, it's important to make sure that we're especially intentional about that protein component in order to help protect our muscle mass. Now you'll hear all sorts of numbers when it comes to protein goals, and the advice that I have for you is to start with where you are and build up to your goals. When we look at the RDA, that is the recommended dietary allowance. When we look at nutrition guidelines, the recommendation is 0.8 grams of protein per kilogram of body weight. So that is considered a minimum, excuse me. But when we do that calculation, what a lot of people will find is that they actually are not even meeting that. So let's do that calculation and then decide from there, okay, is that my first goal or can I build my goal from there? So for really simple numbers, because I love simple math, if we think of a person who weighs 220 pounds, if we convert that into kilograms to convert kilograms to pounds, we take 220 divided by 2.2. You can see why I chose this number because that gives us 100 kilograms. Now, someone who weighs 100 kilograms and needs to eat 0.8 grams of protein per kilogram of body weight per day needs to look for 80 s of protein in their diet. Let's look at some other numbers though. So if a person weighs 300 pounds, for example, we can divide that by 2.2. And when we divide that by 2.2, that gives us 136 kilograms. Multiply that by 0.8 and that will give you 109 grams of protein per day. Someone who lives in a body that's 150 pounds, divide that by 2.2 to get our kilograms that is 68 kilograms. That person, 68 kilograms times 0.8 would be 55 grams of protein per day. So the amount of protein that you need will be dependent on the size of your body, and that will change over time as your body changes in size. And so it could be good to calculate this and pay attention over time to what your body's needs are. So with those numbers as a starting point to ask yourself, okay, what is it that I'm getting right now? Am I adequately meeting those needs? If so, excellent. And how can I adjust that over time to even support that further? So we look at 0.8 being a minimum, and next point would be one gram or even 1.2 grams of protein per kilogram of body weight per day. So using those same body weights, let me give you the calculations for 1.2 grams per kilogram of body weight. So someone who weighs 220 pounds, a hundred kilograms, they would need to eat 120 grams of protein per day. Someone who weighs 300 pounds or 136 kilograms would need to eat 163 grams of protein per day. And someone who weighs 150 pounds or 68 kilograms would need to eat 82 grams of protein per day. So these are really excellent. I would say start with a 0.8 grams per kilogram per day. If you're meeting that feel like that's pretty easy, how can you bump that up to that 1.2 grams per kilogram per day goal? Now another way, if you're like Dr. Stombaugh, I do not want to do math. I don't want to be doing a bunch of calculations, another thing you can do is have about a third of your calories coming from protein. That is a great way to estimate. Getting about a third of your calories is often going to give you adequate protein. All of these numbers are for people who are moderately active, someone who is intensely active. So someone who's doing a very intense bodybuilding, power lifting regimens, something like that, really trying to increase their muscle mass in a significant way may be getting even higher protein goals. So sometimes if you google this question, how much protein should I be getting during weight loss? You'll get crazy numbers. People saying, not even just a hundred, but 150, 200, 300 grams of protein per day. And while that might be the right answer for certain people, the reality is it will probably not be the right answer for you. Now, if you listen to those grams of protein and you're like, Dr. Stombaugh, that is a bajillion calories. If I ate 120 grams of protein per day, that would be a really significant number of calories. Let me tell you, there are, excuse me, four calories in a gram of protein. So a person who is getting 120 grams of protein times four calories, per gram is getting 480 calories total from that. So if you were like, I would burn all of my calories just by eating protein, do not worry. You should be having with that calculation, 480 of your calories coming from protein, but you'll still have plenty of calories for carbohydrates and for fats are other macronutrients. So now that we've talked a little bit about that protein goal, we spent some time on it because I do think that that is really important. I want to talk a little bit about emphasizing other nutrient dense foods in the diet. One of the things that happens, especially when you're taking GLP medications is that your appetite is just decreased. And with that, you may find that you're starting to eat food and then you're a few bites thin and you're just done. You even felt appropriately hungry before the meal. Now you've had a few bites and you're like, oh, my appetite is completely shut off. So with that, one of the things that I'm especially intentional about for my patients who are taking GLP medications is that we're thinking about foods that are going to provide great nutrients. So certainly protein, but also thinking about things like vegetables, things that are going to be fiber-rich and micronutrient-dense. Micronutrients being things like vitamins and minerals. We do recommend to all of our patients to take a multivitamin. A multivitamin is a great way to make sure you're getting all of your micronutrients in. And honestly, any old micro or multivitamin will do. We do not recommend ones that are gummy because those can be challenging or not good for your teeth. But honestly, anyone that you get at your traditional drugstore is great. You do want to be intentional about your other nutrients, recognizing that you only do have so much food that you're going to consume throughout the day. As long as you're emphasizing protein, thinking about those fiber rich foods, those are going to be your top priorities. And then building in other things afterwards. In my program, one of the things that I'm really intentional about is that there's no foods that are completely off limits. So foods that are less aligned with our health goals, we want to be really intentional about how we consume those. We want to choose to consume them in very high quality aversions in a very intentional amount, on a very intentional occasion, but we should make sure that we're including them. So this looks like, for example, having a slice of really decadent birthday cake on your own birthday, eating to your own satiety cues and stopping when you feel appropriately satiated as opposed to, I have young kids, so we're often at young children's birthday parties and people have grocery store cupcakes, and they're like, okay, but they don't really do it for me. And so it would mean skipping on the grocery store cupcake at my kid's friend's birthday party, but really enjoying and savoring every bite of a piece of cake on my own birthday, for example. And you can imagine how this would apply in a lot of different ways, but just really being intentional about how we incorporate those foods that are a little bit less in line with our health goals. The other thing I want to think about is exercise and making sure that we're moving our bodies in ways that are meeting our weight loss goals. So this will look like both movement in general as well as resistance training. Again, I believe very strongly in one, doing what you love and two, in starting where you are and building from there. So thinking about movement that really feels joyful for your body that you really enjoy doing that feels energizing for you is so, so important. And we think about long-term success. Finding things that you enjoy is one of the best ways that you can achieve that. Additionally, we really want to be mindful about resistance training, thinking about how we are supporting our muscles, and then also supporting our bones such that during our weight loss journey, we're not just losing weight, but we're actually improving our health. So making sure that both of those pieces of exercise are in there. Also, thinking about that planfulness piece, being really intentional about how we're incorporating foods into the diet, making sure that we're focused on hydration. A lot of times as our hunger signals are turned down, we'll find that our thirst signals get turned down as well. And so making sure you're mindful of not just eating intentionally throughout the day, but drinking throughout the day, drinking, not just being water, but making sure you're getting plenty of electrolytes as well, getting sodium, getting potassium, getting magnesium. All of those things are important because when we're losing weight, there's often a diuretic defect that comes with that, and our body can get really easily dehydrated. So the electrolyte piece is really, really important. I do want to say there are certain electrolyte supplements that do not include magnesium, so I like to look for ones that do. My favorite two brands are elements, LMNT and the brand Sowell, S-O-W-E-L-L. Those are both excellent brands that will support you in getting electrolytes, especially that magnesium component. The last thing I want to address before we turn it over to some questions is thinking about the rate of weight loss. Now, this is where the part of this is individual to your body, and it's hard to say from the beginning what your unique response will be, but there are some general factors that we can consider. So on average, I like for my patients to look for about a one to two pound per week weight loss. When we are going much faster than that, that can be a sign that we are not adequately giving our body the energy, especially the protein that it needs. There is often an initial diuretic effect that happens. So sometimes in the first couple of weeks on medication, there can be a really significant drop in weight, but we often will notice that even if that happens initially, it slows down a little bit thereafter. Now, there are some people for whom their weight loss is a little bit slower than that. That can happen for a few different reasons. Some of it is just your response to the medication, but there are things like insulin resistance, for example, that will change the impact of the medication. For example, when we look at studies of Ozempic, the semaglutide medication that is branded for the treatment of type two diabetes, we look at those studies of Ozempic versus Wegovy. We look at the different patient populations. We know that people who have type two diabetes actually have less weight loss from these medications compared to people who do not have type two diabetes. So we do know that insulin resistance in general plays a role in weight loss. Now, the GLP medications are one of the best things we can do to improve insulin resistance, but we do know that weight loss may be slower for people who have those underlying signs of insulin resistance. We also know that what you're eating, how your body's moving, and all of that plays a role as well. So if you're finding that your weight loss is a lot slower and you're feeling super frustrated in your journey, here are some things I want to advise you. One, do check and see where you're at from a protein standpoint. Make sure that you're hitting those protein goals. And if you're not, work to bump those up slowly over time. Two, I want you to think about some of the side effects. For example, make sure that you're fueling your body with appropriate energy. One of the things we see very commonly is that nausea is common side effect from the GLP medications. And in our society, we're often taught that we should be sipping soda, maybe having some crackers, things like that in order to reduce our nausea. And what happens though is we're actually putting ourselves in a place. Those foods, even if we're treating them sort of medicinally, they're fuel for our body that our body, that's not going to be in line with our weight loss goals. And so when you're feeling nauseated many days of the week or most days of the week, you don't want to find yourself in a situation where you're relying on soda, relying on crackers and things like that to help yourself feel better because that's really not in line with your weight loss goals. So are there shifts that you can make? We often recommend protein waters, protein shakes, bone broths, for example, electrolyte beverages as ways that you can reduce nausea without getting that added sugar. So are there shifts like that that you could make in your day? That is often one thing we see. The other thing is making sure you're getting that resistance training piece. Now, the interesting thing here is that when we look at the density of muscle compared to fat mass, muscle mass is going to be much smaller in volume compared to fat mass, but you may not see the same shift on the scale. So we're often looking at the number of scale and tracking that over time, but tracking other things can be really, really important as well. That could be numerically tracking, tracking your waist size, tracking your clothing size, for example, but also tracking your non-scale and non-numerical wins. So paying attention to how you fit in space. When you sit down in your office chair, when you sit down in a movie theater in an airplane, does your body fit in that space differently? Does it feel differently? Are you able to walk a further distance? Are you able to enjoy activities like biking or horseback riding or things that you haven't done in some period of time? Paying attention to these non-scale wins is super, super important. And especially for that person who is working on resistance training, working on building their muscle mass, we sometimes see that the movement on the scale is slower, but that's not necessarily a bad thing. They may see that the movement on the scale is really slow, yet their pants size is progressively, their pants are getting too large. They see that that pan size is getting smaller. And so there are other things that we can pay attention to see, okay, it's not just about the number on the scale, but how is my body feeling? How is my body functioning for me and am I adequately supported in this weight loss journey? Now, the great news for all of these medications is that there's a lot of doses available. And so everybody is advised to start at that low dose and to titrate up over time. In The GLP guide, we have some recommendations about what to look for to know if you should be adjusting your dose. So definitely check that out. But it's worth having a conversation with your physician as well. Are you feeling like, Hey, things are going slow. A lot of the food noise and hunger is coming back. Those are absolutely signs that you might want to be adjusting the medication. So making sure that you're having those conversations regularly. Alright, I could talk about this all day long, but we are going to pause and move over to talk about some questions. I know that we had a handful that were emailed to us and I think a few more that have come in during the talk. So what I'm going to do now is bring on Maryam. Maryamis my assistant in the practice and my right hand gal. Maryam, thank you for joining us. Tell me what questions are you seeing come in. Maryam: Yeah, we actually got a good number of questions. So first off says that I took the Zepbound injection last week, but I didn't even feel the needle. Now I'm not sure if I got the medication or if I just wasted it. Dr. Sarah Stombaugh: Yes. Okay, excellent. It's really interesting. We've had this question asked to us a couple of times for all the medications that are in the single dose injection pens, those medications have a teeny, teeny tiny needle and you don't ever see it, touch it, handle it, anything like that. And so for people who are injecting with those pens, they don't always know. They're like, did it go in? I hope so. So it's interesting because it's such a small needle that it is actually possible that the medication would've gone in and you wouldn't have even felt that one side to look for. On the side of all of the medications, there is a little window and there's a plunger. So you should look to see that the plunger has actually moved down to see that the medication has gone in. So that's best thing. The other option though, it requires a little bit of waiting, but if you took the injection, let's say on a Monday, you should be feeling in the next two days that that medication is kicking in. And if you feel like it is not kicking in, it is possible that there was a pen failure or something like that. But if it does show that the medication deployed, then that is great. I would contact your doctor, talk to your pharmacy if there's any concern about a pen failure. Occasionally we've had patients, especially with the Wegovy pens, and maybe that's just a coincidence who've had the pens sort of squirt all over the place. So something like that is obviously concerning, but if you didn't feel it, pay attention or you're feeling the effects from the medication. And if so, it is probably working and just thank goodness you didn't feel it. That's lucky. Alright, tell me next question. Okay, Maryam: Is it okay to use semaglutide for a few months to kickstart my days? Dr. Sarah Stombaugh: Okay, maybe. So this is a question in social media, there's been a narrative over the last few months of using some of the GLP medications as a short-term option to kickstart your weight loss goals. And as a general rule of thumb, I would say no, it's really not designed for that. We do know that when we look at weight loss, we look at the underlying mechanisms, we look at the physiology that lead to chronic excess weight. These medications can be really effective at supporting those while they're in our system, but they don't necessarily make chronic changes to our underlying physiology. So while the medication is in our system, it can be active, it can be very effective, and that's great, but if we stop the medication, we may find that our hunger sort of comes back with a vengeance. Now, there is a little bit of a caveat to this because there's other factors to consider our muscle mass, for example, and our behaviors. And so a lot of times if we're able to use these medications in a way that we're starting to learn the foods that fuel our body make us feel really good that we can utilize those to keep up with those choices that we can start participating in activities like resistance training where we're really focused on building our muscle mass, reducing our fat mass. There are patients for whom we will see are able to use these medications for shorter periods of time. But for one, I don't recommend abruptly stopping the medication. You should start on, well, everyone will start on a low dose and kind of slowly stair step over time as we need to. And then if you're hitting your weight goals, you and your prescriber may decide to go back on a dose, for example, and see, Hey, how am I doing? Then you can take another step back. For example, there are patients for whom we know based on studies, based on people sharing their stories on social media that there are people who do stop these medications effectively. But most people will find either one being on the medication really supports them in hunger, in food noise, and so they really like being on the medication. So I really would consider it as a long-term medication use and recognizing that starting this journey, that would be what we're typically thinking of. So probably way more than that person bargained for, but there you go. Alright, next question. Maryam: Okay. This one says, I thought my appetite would be depressed when I started on Zepbound, but I'm still very hungry most of the time. Okay, Dr. Sarah Stombaugh: Interesting. So if you're just starting out on a medication, most people will feel the effect of the medication within a couple of days. So these are long-acting medications designed to be injected once per week, so it can take a day or two before the medication is really kicked in. And then even as we look at the next couple of weeks, the medication can start to build in your system. So there are people for whom maybe because of insulin resistance or because of just their own physiology and how their body is processing medications that they may not necessarily have as significant of an impact as others, so that maybe someone for whom they are needing to titrate up on the dose over time for everyone. We do recommend being on a starting dose of medication for at least a month or at least four injections before deciding, okay, yes, I should be thinking about moving up to the next injection. I would also really be thinking about what are the food choices that you're making? Because a lot of times if there is any nausea or anything like that, and this person doesn't sound like they're having that at all, so maybe I'm assuming. But if there is any nausea or anything like that, as I kind of mentioned in the talk, sometimes that leads us to starting to fuel our body with simple or processed carbohydrates. Things like sodas, things like saltine crackers, and we can set ourselves up for a situation where we're not actually supporting ourself with nutrition tools that are going to support weight loss as well. So making sure that we are emphasizing protein, emphasizing fiber in the diet, those are going to be really important. But I think more than anything, it's probably just giving it a little bit of time and seeing, okay, how is this kicking in with my body? And then talking with your provider about adjusting the dose upwards if you're really not feeling it, I guess also make sure you are injecting it properly and I don't know, hopefully that was not the same person who asked about, I didn't feel the needle go in. Maybe it's a sign that the injection isn't happening properly, and so do confirm that your injection is happening properly. All right, next question. Maryam: Alright. Okay. So the other one says that I've been so nauseous ever since I started Wegovy last week. It was so bad the first time that I did it has improved a bit, but still a little crazy. The only thing that I can stomach is some crackers and ginger ale. Dr. Sarah Stombaugh: Okay, so that is exactly what we were talking about where in our society we often have this idea that soda, Gatorade, ginger ale, things like that are going to be really supportive of our nausea. And if you have a stomach bug and you can't keep anything down, it's not that I'm saying don't have those things, but as we're taking the GLP medications and creating a situation sometimes where we do feel nausea as a result of these medications, we can find ourselves in a situation where you're having a lot of simple processed carbohydrate, these sugars and flour that are not in line with our health goals. And so for that person one, I would shift what they're doing to make sure that they have a good electrolyte beverage to make sure that they're getting plenty of protein. If you're really feeling nauseated, sometimes at least for me, milky or thick substances, just I'm really ugh, so something clear is much more appealing. So something like a protein water is a great option. Something like bone broth, having that really ice cold can be more refreshing and can help with nausea a little bit more. And then that electrolyte part, you can actually make a beverage where you mix protein, water and electrolytes together and have that as a single beverage and sort of sipping on that can be a great option. So I would definitely try that first. There are prescription medications available, so for people who are on these medications and feel like maybe just for a couple of days after taking it, the nausea is pretty significant. There are medications like Zofran or Ondansetron that can be used to help reduce nausea that is a prescription, so you would need to talk to your prescriber about that. I do caution anyone who uses those medications is that it can cause constipation. So especially with ozempic, those tend to be a little bit more anyway. So you just want to be really intentional that you're not doubling down and creating worse constipation for yourself. But Zofran is an option, but I would definitely try some of the electrolyte beverages and protein waters as a first option as well. All right. Do we have other questions? Maryam: We do actually. Yeah, the other one is I have a one week trip coming up and I'm really worried about bringing my Zepbound medication with me. What are my options? Dr. Sarah Stombaugh: Okay, excellent. So this comes up a lot when we're traveling, especially if it's our first time traveling while on the GLP medications, it can be a little nerve wracking to think about. So with Zepbound, I guess assuming that this person is using the single dose pens, so a traditional Zepbound prescription, every month you would get four single dose pens and each week you would use that one, then you would throw it in the trash can when you were done. We think of these medications as being refrigerated and generally they should be, but the Zepbound medication can be out of the refrigerator for 21 days. And so if it sounds like this person's trip is a week long, so one option is that if your injection day is going to fall while you're away, you can just take a single Zepbound pen, toss that into your purse and bring it with you or briefcase or backpack or something I guess if you're a man or don't have a purse, but you want that medication to stay at room temperature. So it is safe out of the refrigerator, but it does need to stay at room temperature, which is 59 to 86 degrees Fahrenheit, I believe 15 to 30 degrees Celsius. So what that does mean if that you're traveling by car, traveling by airplane, you don't want it to be in the trunk of your car. You don't want it to be underneath the airplane. You want this to be sort of on your person. So you want it to stay in your purse, in your carry-on bag in the cabin of the airplane just so it doesn't get any of those extreme temperatures. So that is actually pretty easy. I do think a lot of people are nervous about going through TSA and it's a teeny tiny volume. It's 0.5 milliliters in each injection. So it's a small volume. You do not actually even have to declare it. So you could literally just toss this in your bag, put it through the security checkpoint and not say anything. For people who are traveling internationally, we do recommend to have a list of your prescriptions or a note from your doctor with all your prescriptions on it just so that you don't run into any issues with customs because that can occasionally be an issue. Something like a single dose, that bound pen is unlikely to be though because of course it's labeled with the medication. But certainly if you're someone who's using vials, for example, you want to make sure that everything is properly labeled because that would get thrown away at customs. So one, you can bring your medication with you and it's actually a lot easier than most people think, but then two, depending on how you're feeling on the medication, I have some patients who decide to space out or do their doses on a different day. So let's say you're traveling weekend to weekend, you're leaving on a Saturday, you're coming back the following Saturday. If you typically inject on a Friday, for example, you could inject Friday right before you leave, go on your trip, and then when you come back the following Saturday, even though it's been a full eight days now, go ahead and inject them moving forward. If you've done that, I would continue with Saturday as your injection day. Although most people can sort of work back if they've been on a dose for a while, might be able to do every six day injections the following week just to sort of bring them back to schedule or do every eight day injections for a little while to get them to a new date. But you can sort of adjust the timing of your dose. And this is particularly true for someone. It's interesting. The medications are long acting. They're once a week. It takes about six weeks for the medication to get out of your system completely. There are patients for whom like day six or day seven, right before the injection, they're ravenous, they're feeling it, they're like, I'm ready for my next dose. And then there are patients for whom the injection day comes and they're like, yeah, I'll inject because it's my injection day, but I could probably wait a day or two. If you are the person who by injection day is not feeling overly hungry, overly ravenous, it may make sense to extend your schedule by a day or two, not in general, but especially for a travel. And so you have that as an option. So again, probably way more than that person bargained for we do in the GLP guide have some good answers to those questions. And we talked about the Zepbound, but there are differences if you're taking Wegovy, that's 28 days out of the refrigerator if you're taking a vials and that type of thing. So we do have videos actually addressing traveling with each of the different medications in The GLP guide. So that'll be a great resource. All right, next question. Maryam: I've been on 0.25 of Ozempic for three months now. First two months was great, and I've already lost 10 pounds in the last two weeks. It seems like my weight has not been moving. I dunno what to do. Dr. Sarah Stombaugh: Okay, so the short answer is that that person should increase their dose. The ozempic dosing, it's interesting. Ozempic has become sort of the poster child for semaglutide medications. Ozempic is the one that's technically FDA approved for the treatment of type two diabetes will go via technically for obesity. And then semaglutide is the compounded version that people are using pretty frequently. When we look at the dosing, the standard dosing starts at 0.25, moves up to 0.5, moves to one, and then depending on if you're taking Ozempic, Wegovy can go to 1.7 for Wegovy. And then 2.4, if you're doing Ozempic, it goes from one to two milligram dosing For people who are using compounded doses, there are often some in-between doses as well. So 0.25 is really considered a starting dose of the medication and there's room for bringing that dose up. And so I do think it makes sense to, if you're having good effect of the medication, there's no reason you have to push up on the dose. And so if that person, the first month it sounds like was going really well, the second month even sounds like really going well, losing 10 pounds in two months is a really nice trajectory to be on, especially depending on how much weight they had to lose initially. But regardless, it's a pretty good trajectory. So it makes sense to me that this person was advised, Hey, go ahead and stay on the 0.25 milligram dose. But the reality is it's probably time for them to move up to that 0.5 milligram dose. So it is something, if you're thinking about adjusting doses, I do recommend doing that with your prescribing provider. So do discuss that with them. But we want to be bringing that dose up to help meet your weight loss goals and sort of paying attention to how it's feeling in your body. All right. Do we have other questions? Maryam: Yes. I'm so happy. I've been losing so much weight since it started Wegovy. I think it's okay if I stop working out now. Dr. Sarah Stombaugh: Yeah, so it's interesting because working out exercising comes up a lot and I think exercise has so many important benefits and whether we're talking about weight loss or just in our general health. So the role of exercise in weight loss is interesting because you can lose weight without exercising at all. There are patients for whom, especially people who have maybe chronic injuries or chronic pain, especially hip or joint arthritis, for whom they're like, they're kind of in this catch-22 because they want to be able to lose weight. Maybe they've lost weight with exercise in the past. And now that they're not able to do that, it feels really frustrating because they feel like they won't be able to achieve their goals. So really interestingly, it is possible to lose weight without exercise, and exercise is really, really important. So for a general health, when we look at our cardiovascular, our cardiopulmonary fitness exercise, particularly walking, running, jogging, biking, dancing, things that kind of get our heart pumping are really important for getting our heart pumping, keeping our heart strong, keeping our lungs strong, working, improving our vascular health. So that will apply regardless of of your body size, regardless of where you're at in your weight loss journey. Exercise and movement is really important for us, but especially in the weight loss journey, the piece that I think is so important is that muscle building, that resistance training component. A lot of times if we are eating less, our body may feel like it can slow down its metabolism because it doesn't need to burn as much energy. Our body is becoming smaller, it requires less energy to fuel that body. And one of the things that can really keep our metabolism up and going is to have plenty of muscle mass on our body. So regardless of, I think everybody probably needs more muscle except for maybe Arnold Schwarzenegger, but regardless of where you're at in your weight loss journey, that resistance training piece, keeping up with it is really, really important. And so I would advise for someone to keep up with that. Certainly if you're like, I am worried that I've gotten injured, I've hurt myself in any way, make sure that you're working with a personal trainer or someone who can support you so that you're not going to further injure yourself. But I do think that exercise is an important long-term piece. Alright, let's take two more questions before we wrap up. Maryam: Good. Yeah. I've been having a lot of constipations since starting Ozempic, are there any medications that I can take that are safe? Is it okay to use laxatives long term? Dr. Sarah Stombaugh: Okay, excellent. So constipation is common, especially with the semaglutide products. So the Ozempic and Wegovy medications in our practice, we do recommend fiber for everybody. Fiber is a really phenomenal tool in your weight loss journey because fiber actually slows down digestion and can help with weight loss, sort of independent of the GLP medications. But one of the things that it does is help to provide a soft bulk to the stool. So when we take fiber, especially with plenty of water, that can help to support having enough bulk in the stool to move things along. So especially when we're really emphasizing protein in the diet, that may come at the expense of having less vegetables. Sometimes it can feel like so much volume. So a fiber supplement can be a great way to support that. So we do recommend a fiber. You could take a fiber supplement every day for the rest of your life and that would be totally fine. You can decide what makes the most sense based on your preferences. Benna fiber is a great option. Metamucil is a great option. The main ingredient in Metamucil, which is cilium husk, you can buy that, which is then just a plain dissolvable fiber option. Metamucil typically is flavored, so some people like that, some people hate that. Do make sure you get the sugar free version because traditional Metamucil has a lot of sugar and that's kind of silly if you're trying to lose weight. There's also capsules and gummies and lots of good Metamucil options. So I do recommend fiber. Like I said, you could take it every day for the rest of your life if you need to. The other thing is making sure you're emphasizing dietary fiber, emphasizing hydration, not just water, but that electrolyte component as well that will be really supportive of constipation. Now the other thing is if you're finding you're getting more constipated, you do really need to stay on top of your bowel health and make sure, okay, how often am I having bowel movements when I'm having them? Am I really straining? Because you can create other issues like hemorrhoids or anal fissures, and it can be really simply, it can be miserable to go too long without having a bowel movement. It can also create a lot of abdominal or bloating, pain and discomfort. So don't do that if you find that using fiber alone is not enough. I do recommend adding on a laxative that can look like a few different things. One of my favorite options is magnesium. Having this as a regular supplement as part of your electrolytes is great because it can reduce constipation as a lot of other benefits as well, like improving sleep, decreasing anxiety. So magnesium is excellent. You can buy versions that are specifically for constipation. So things like magnesium citrate, if you're finding yourself getting constipated is a really good option. You can also try things like MiraLax or Senna. A lot of people really like Senna because it's available in a tablet. It's also completely natural. So it's plant derived. It's available as a tea. So if you've heard of smooth Move tea that is derived from Senna. So those are great options. You can do either of those long-term, but if you're finding that you're having constipation that's significant enough that you're wanting to use or feeling like you're needing to use a laxative nearly every day or every day, do make sure that at your next appointment you're discussing that with your physician because it may be a reason to switch to another medication. Tirzepatide tend to be less constipating compared to the Ozempic and just to make sure that there's nothing else going on. So do bring that up at your next appointment. Alright, and I think I said one last question before we wrap up. Maryam: Yeah. Okay. To cap everything off I have here, what is the best diet to follow while using healthy medications? Dr. Sarah Stombaugh: I love that. Okay, so patients in my practice will know that I do not recommend a single specific diet, or I do, and I call it like if Maryam was my patient, I would say the Maryam diet. So it's important to have a diet that is individualized to you based on your preferences, based on your health goals. The most important thing is that you're eating foods that you enjoy. So thinking about and being mindful of what are all of the foods that you really enjoy that are also in line with your health goals. Emphasizing those super, super important, pay attention to your protein goals, making sure that you're hitting protein, as we talked about earlier on, making sure that you're getting plenty of your fiber and that any of those foods that are less in line with your health goals. So particularly things that are sugary that are flour or things that are really heavy or greasy. For one, those may just feel bad in your body on a GLP medication. But when you're choosing to have those medications that there is a choice. It's something that's very intentionally incorporated. And creating a healthy relationship with our food is so much more important than following any one specific diet. There's so many diets out there that eliminate whole food groups or rely on calorie counting or other techniques that just feel really restrictive and not sustainable. And so my goal is to support patients in finding something that is fueling their body, that feels good in their body and feels enjoyable, that they're really enjoying their foods. So keep in mind these different components, the fiber, the protein, the hydration, and then building in the things that may be less in line with your goals. And that is the recording from The GLP Guide launch Party. I had so much fun teaching and sharing about this topic. It is really a passion of mine to make sure that people feel adequately supported in their weight loss journey. And the GLP guide is the best way to do that. If you or someone is taking one of these GLP medications, you will want to have this GLP guide handy. It is an amazing resource to address all of those most commonly asked questions. And it is only $97 for a full year of access. And the best part is if you are reviewing the videos and you realize that the answer to a question you have is not listed there, you can email us at info@sarahstombaughmd.com, let us know what that question is. We will make a video and add it to that library of resources for you and everyone else who has access to that. And I am so excited to share and grow this resource with you. If you would like to purchase it, you can go to www.sarahstombaughmd.com/glp. Thanks so much for joining me for today's episode. We'll see you all next week.