Conquer Your Weight

Dr. Sarah Stombaugh: 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 today's episode. We are talking about a couple of topics that came up recently while I was recording videos for our GLP course. I am so excited because we are launching the GLP guide, which is an online course on October the first. And I have been so busy at the time of this live recording, at least recording lots of videos for that project to get all of the information that you need addressing common questions and answers because it is so common that people feel like they are prescribed GLP medications and do not get the answers that they need in order to make their medications as effective as possible or really just to feel like they are supported in their journey. And one of the topics that I made a video on I realized we have not addressed in the podcast yet, and this is a question I get asked all of the time, so I wanted to expand a little bit, share it in the podcast, and you'll get a sneak peek too about what it would be like to be in the GLP Guide course. What kind of things that we are talking about because this is such a cool resource for anybody who is using the GLP medications. Today, we are going to be talking about how quickly should you lose weight and do you need to adjust your medication dose. So let's dive into that because the answer here can be really variable, but I want you to understand some of the factors to consider to understand is your body responding in the way that we would expect it to for these medications. Now in the talk today, I'm primarily going to be talking about Wegovy and Zepbound. Wegovy is the FDA-approved version for the treatment of obesity of semaglutide and Zepbound is the FDA-approved version for the treatment of obesity of tirzepatide. So we'll be talking about those medications and referring to those dosages, but this certainly can refer to any of the other medications like Ozempic, like Mounnjaro, like Saxenda, or for people who are getting compounded medications, semaglutide or tirzepatide. But I simply don't want to make it too confusing talking about a million different dosages, but I am going to use some actual numbers just so that I am clear as I'm providing some examples. So for people who are using the GLP medications, they often want to know how much weight should I expect to lose. Now when we take a step back and we look at the studies of these medications, there are studies that go on for a year or a little over a year for both the Wegovy and Zepbound medications. And on average, patients who are using the Wegovy medication lose a little over 15% of their total body weight. And patients on the Zepbound medication lose a little over 21% of their total body weight. Now the interesting thing, the Wegovy tirzepatide studies also looked at taking Zepbound in combination with what they call intensive lifestyle intervention, intensive lifestyle treatment, things like nutrition, physical activity, stress management, sleep, all of that. We'll talk about how those play a factor. But interestingly and honestly, not surprisingly, for patients who used these, that Zepbound medication tirzepatide in combination with intensive lifestyle modifications, they had an average of 26.6% of total body weight loss. Now, the really cool thing here is that those are just averages. And so we hear all sorts of stories of patients who are more or less successful. And so you will have an individual journey on this and you will get to work with your physician, with your provider in order to have the best success possible. So I am an obesity medicine physician. If you are not working with them and you get to the end of this podcast and you're thinking, gosh, I really have a lot of questions, I'll give you some great information about how you can seek out an obesity medicine physician in order to really get some of your questions answered, or you might want to purchase our GLP guide, which is our online course for only $97. That addresses many, many, many of the common questions that people have when they are taking these GLP medications. So that being said, we've got 15% total body weight loss a little over for patients using Wegovy and up to 26.6% of total body weight loss for patients using Zepbound when combined with intensive lifestyle interventions. And I think that anyone who is in this space will tell you that is exactly what they see. We have patients who are very responsive to these medications and when you're able to utilize these medications in combination with nutrition changes, with physical activity, with stress management and management of emotional eating, of good treatment of sleep and other medical conditions related to weight, you can have really profound success, which is so cool. So when we think about the rate of weight loss, it really will be individualized. But when I think about general goals, I like to recommend that patients are looking for about one to two pounds per week of weight loss. Now, it's really interesting depending on what someone's lifestyle looked like prior to starting their GLP medications. It's pretty common in my practice that I will see patients who lose a huge amount of weight in the first one to two weeks. So not infrequently I will see patients who have lost five or 10 pounds in the first couple of weeks, and it can both be exciting but also a little bit terrifying. Like, oh my gosh, what is happening here? So I do want to explain that because there are people who see this huge effect at first. There are certainly people who don't and we'll talk about why that's the case. But if you start the medication, you lose five to 10 pounds in one or two weeks and you're like, oh my gosh, what is going on with my body? Let me say that is normal and it likely will not continue. We will likely see that you'll slow back down to a more one to two pound per week weight loss goal. So when we think about our energy storage, our body has a lot of different ways by which it stores energy. We have glucose, which is our active form of energy in the bloodstream. We have glycogen stores, which our glucose can be converted into glycogen as an intermediate energy storage. The glycogen stores in our body are held in our liver and in our muscles. And then beyond that, we have our fat storage and our body will burn each of these things preferentially. So our glycogen, particularly the glycogen that is held in our muscles, can hold onto water more readily. And so when we first engage in a intensive lifestyle intervention program, and this can be with or without the support of anti-obesity medications like the GLP, there's often this diuretic effect where we lose all of that extra fluid and so we really lose a lot of fluid weight. So it's very common that people who are new to a program have not necessarily been following a very low carbohydrate program before, maybe haven't been doing physical activity as much in the couple of weeks or months leading up to this program, that when they initiate those GLP medications, as they're depleting their glycogen stores in their muscle, there's this big diuretic effect. They lose that water weight and they see huge shifts on the scale. And like I said, it can be both exciting but also terrifying to see that number just drop down. Now if the number does not plummet, I do not want you to feel badly about yourself. One of the most common reasons that the number does not plummet is that you were already engaging in a program that limited process carbohydrates doing a lot of physical activity. And so you don't have these just huge glycogen stores that your body is holding onto that fluid. But this is one of the main reasons that we see pretty big shifts, both initially in a weight loss journey and sometimes when someone has sort of stepped away from their weight loss goals for a period of time, sometimes weight can come back on really quickly and that is those fluid shifts that are happening. But for everybody, whether it happens initially or for these people who have a major shift after a couple of weeks start to settle into a routine where I like to guide my patients on about a one to two pound per week weight loss goal. Now there are people for whom, depending on how frequently they are checking their weight, they will see that that number pretty consistently goes down. But remember that you are a human with human physiology and depending on how often you weigh yourself, you are not going to see a lower number on the scale every single time. You will find that that number may go up, it may go down, there's days maybe where you're dehydrated. There's days where you had extra salt in your diet and you're a little bit swollen, or maybe you were in a long car trip or an airplane ride and your legs are a little bit swollen. Our weight shifts for a lot of different reasons. And so we do see that there can be fluctuations on the scale, up and down, up and down. But when we really take a step back and average that over a week, over a month, what are the numbers that we're seeing? And looking for that four to eight pounds over a month is really an excellent place to be. Now, there are people who may be moving a little bit more quickly than that, and that is okay, we pay attention to the way someone's body is feeling, how they are handling the medications, are they having some appetite and able to meet their nutrition requirements? When we lose weight, we do want to be really intentional, and we've talked about this before, but making sure that we are hitting our protein goals as we lose weight. Our goal is not to lose weight, but to lose that mass. And in order to do that, we need to make sure that we are doing everything possible to protect our lean muscle mass in our system. One of the best things that we can do is to make sure that we are emphasizing protein in the diet and making sure that we get enough of that in order to support our muscle mass. Now, in addition to that, what we find is that there are some patients who from a side effect standpoint, maybe they have really severe side effects and they just have no appetite at all. So if your weight is moving more quickly than that two pounds per week, take a step back and say, okay, am I hitting my protein goals? Do I have an appetite at all? Maybe you feel all day long like you're forcing yourself to eat, feeling really nauseated, feeling like I really just don't want to eat anything. There are patients who are almost hyper responds to these medications. A very low dose of medication in their system feels very significant, and they notice significantly decreased appetite with nausea. They just don't feel like eating anything. And so I am very cautious in these patients about adjusting their dose upwards. If there are patients for whom they're taking a low dose of medication and they're having really good response to it or having significant side effects, in my opinion, there is no reason to rush the titration there. So all of these medications start at a low dose and are designed to move up overdoses in time. Interestingly, with the studies of Wegovy, there are five doses of Wegovy. There's a 0.25 milligrams, a 0.5 milligrams, a 1.0 milligrams, a 1.7 milligrams, and a 2.4 milligrams. In the wago studies, patients were pretty quickly moved from one dose of the medication to the next until they reached the treatment or maintenance doses of the medication. Those are considered the 1.7 milligram dose or the 2.4 milligram dose. So what that looks like is patients were started on the 0.25 milligram dose. They were given that for four weeks. As long as they were tolerating it well, they were bumped up to 0.5 milligrams. As long as they were tolerating it well, they were bumped up to 1.0 milligrams. As long as they were tolerate well, they were bumped up to 1.7 milligrams. And then depending on how patients were doing, they could either stay at the 1.7 or bump fully up to that 2.4 milligram dose. Now interestingly, when we compare that to the Zepbound tirzepatide studies, they actually studied three treatment doses of medication. So there are six total doses of Zepbound. There's a 2.5 milligram dose of five milligram dose, 7.5 milligrams, 10 milligrams, 12.5 milligrams, and 15 milligrams. Now, they did study the five, the 10, and the 15 milligram doses of the medication as treatment doses, which is really nice because it gives us a broader opportunity to use these medications and not run into issues with our insurance. So as a prescriber, and I think most people who prescribe these medications would agree there is what you would like to do based on how a patient is tolerating the medication, based on their side effects, the effectiveness, all of that, we may decide that we would want to move more slowly through the doses. Unfortunately, some insurance companies have put limitations on the number of titration doses that you can take such that frequently patients are limited to taking a dose that's in the titration range for often two months. So luckily I don't see this too often, but what that means in practicality is that let's say someone started on Wegovy and they were taking the 0.25 milligram dose and let's say they were just responding really well to the medication, it was very effective in their body, but maybe they had some side effects with it too, and they're having phenomenal weight loss success. They feel like it's working well, and they take the medication for a month and we say, okay, you're doing great. Let's keep you on it for a second month. They take it for a second month. And then let's say they're still doing well and I'm thinking, Hey, let's keep them on the medication for a third dose, one or a third month rather. One thing that sometimes happens is that we'll send that prescription to the pharmacy. The pharmacy will run the insurance benefit, and they'll get a do not pass go. This medication has been denied. And the reason is the insurance company says you can only take this titration dose for two months before you have to move on to the next dose. So sometimes this happens and we have to do additional paperwork to say, Hey, we need an additional prior authorization here. We're requesting longer treatment with this lower dose of medication because of side effects, because of X, Y, Z, whatever it is they're dealing with. And that can be really, really challenging. So most people would agree that if someone is doing well, you can move them along in the doses, but you can do that slowly. There's no reason to rush. Unfortunately, though we do run into some snafus with how long someone is able to be on those titration doses of medication. Now the nice thing about the Zepbound medication is that five milligrams, 10 milligrams and 15 milligrams are considered the treatment doses, but we do still run into that titration issue if someone's doing really well on the 2.5 or the 7.5 or the 12.5 dose simply, I don't see any reason if let's say 7.5 is the dose that's working really well for a patient, is there any reason that we would move them up to the 10 milligram dose? I certainly don't think so, but we may find that the insurance companies are going to require that, and so there may be more paperwork required in order for us to continue to support a patient on the best dose of their medication. So if you've run into that either as a provider or as a patient, I'm wondering a little bit about what's going on there. That is, unfortunately it's not super common, but we do see that from time to time where there are some limitations and how often you can prescribe certain doses. So I will look at a patient and think about how is the medication feeling in their body? Are they feeling the effectiveness of the medication? Are they feeling side effects of the medication? And what are the numbers that we're seeing on the scale? And based on that, we'll decide do we continue at the current dose versus do we increase the dosage? And so I am looking at things like do they feel good? Do they feel appetite suppression? They don't feel like a lot of food noise or over hunger is sort of creeping back in. Are the side effects minimal or if they're there constipation or nausea can be common, but they're dissipating quickly or they're very well managed, and are we seeing that they've lost that four to eight pounds that we would anticipate in a month on this scale? And I do like to check in with my patients about once a month to make sure that these medications are working well for them, feeling good in their bodies, and then we can support them in making the next decision for what that future dose will be. So we're looking at all of those factors to consider. Now, interestingly, when we think about this, there are some people who are faster and there are some people who are slower. A lot of times people kind of fall into the routines. There may be times where you go on vacation and the food choices were less in line with your health goals. So you may notice that things slow down, but you recognize that there were a lot of external factors there. Certainly that can be a thing. And for people who are feeling like, okay, things are moving more slowly, that might mean, Hey, it's time for us to make it a dose adjustment upwards. But we can also take a look at those lifestyle factors to make sure that we are optimizing those alongside your medication in order to overall best support your health goals. So what are you doing from a nutrition standpoint? Are you getting plenty of protein? Are you getting plenty of fiber rich foods? Things like vegetables, things like fruit, things like grains in their whole form. Are you engaged in physical activity, doing some cardiovascular activity like walking, jogging, biking? Are you doing resistance training? Things like lifting weights to improve and support your muscle mass. Have you been getting coaching and other psychological support to support you throughout this? A lot of times we find that patients have this psychological relationship with food and really thinking about that addressing any underlying stressors. Things like stress eating or other emotional eating is so, so important for having long-term success with weight loss. And then thinking about any other medical factors as well. I really like to think about sleep, which is absolutely one of the most important things you can do in order to improve your overall health and your weight if you have sleep apnea, has that been diagnosed, has that been treated? And making sure we're optimizing other things, maybe other medications or other aspects of your health so that you are able to get the most effectiveness as possible from your medications. Now, one of the things that it's wonderful when it happens, we sometimes see that patients are starting to approach their goal weight, and with that we really have to be paying attention to a few things. So one, it is common that weight will slow down as you have less weight to lose. If you imagine starting your weight loss journey at say, 250 pounds, when your body weighs 250 pounds, there is simply more weight to lose than when your body weighs, let's say 170 pounds. So even if you desire to continue supporting yourself in your weight loss journey, things might move slower, and that can absolutely be normal. The other thing to think about here is that there are some people for whom, especially if they started out at an elevated weight but had less than a hundred pounds to lose, like in 50 to a hundred pound range, it is common that patients may sort of get to their goal weight and their body is still dropping weight. They find that they still have really significant appetite suppression and they're feeling maybe tired or fatigued or run down. And those can be a sign that maybe we're overtreating you at this time and we need to back off a little bit. Make sure you're getting enough energy, you're getting enough calories, your body is feeling appropriately fueled because that fatigue and overt tiredness can be a sign that your metabolism has just really slowed down. So making sure that you are getting plenty of food, which sometimes means backing off on the medication dose. So even if a person has been doing really well on a certain dosage of medication, we may find that eventually they may want to take a lower dose of medications or sometimes two, we'll even space out the frequency of dosing. So for weekly medications like Zepbound or Wegovy, these are designed to be taken of course every seven days. But there are patients for whom as they're getting to a maintenance weight or as they're hitting their goals, they may decide to start backing off and taking it every 10 days, every 14 days. I have heard of patients who do it more, even more spread out like every 21 days. That is pretty rarely working well for patients. Most people find that the 10 to 14 days can work well for them, but again, this is really going to be dependent on the individual. There are some people for whom they try taking it every 10 days or try taking it every 14 days, and that really just feels miserable in their body. So maybe they'd like to continue taking it at even a lower dose at the same frequency. So there's some options here where you can adjust the dosing, especially as you're losing weight and getting closer to your goals. If you need to slow down, you can stop these medications abruptly. So if you need to for some reason you've had a major injury, you have a major surgery coming up, you find out that you're pregnant, maybe you have a very severe side effect to the medication, it is safe to stop the medications abruptly. We do not recommend that, and these medications are recommended for long-term use. So most people will find that they want to continue taking the medication. They may need to continue taking it at the treatment dose. They may find that they're supported on a lower dose, but this is really going to be dependent on the individual. One of the things that I find most damaging, there has been a narrative, especially in social media recently, that these medications are good for short-term weight loss goals. And while that may be true for a small subset of the population in general, these are designed for long-term use. There may be dose adjustments, there may be backing off on the dose depending on the individual, depending on how it's feeling in their body, depending on their weight and health goals and what that is looking like. But generally, we do not recommend stopping these medications. Now, if you've listened to this episode and it's brought up a lot more questions and you're wondering what is the best thing for me to do, I would encourage you to make an appointment with a board certified obesity medicine physician. There are a lot of people who are prescribing these GLP medications, and I think that is awesome. I am so happy that people are learning about these medications, getting more comfortable, prescribing them, wanting to be able to support their patients in these ways. But it's also really important to recognize that there are a lot of nuances that come with prescribing these medications and helping patients to decide what is the most effective dose, how can they be best supported in this? So the best thing that you can do is have an appointment with a board certified obesity medicine physician, such as myself, but there's a lot of us out there. I see patients in my office in Charlottesville, Virginia, and by telemedicine throughout the state of Virginia and in Illinois. But if you are elsewhere, go to the American Board of Obesity Medicine. They have a provider finder on their website where you can put in your city and state, you can put in your zip code, and you can look for an obesity medicine physician by you because it is so important to feel like you have a partner in your weight loss goals. We are so excited also to bring this GLP guide in order to best support anyone who feels like they just need that additional information, that additional support. So do make sure to check that out. It's on my website at www.sarahstombaughmd.com/glp. You can get the link there in the show notes as well. Thank you so much for joining us for today's episode. We'll see you all next week.