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:
If you have been thinking about stopping your GLP medication because of side effects, I want you to listen up. Today we are talking about the most common GLP side effects of medications like Ozempic, Wegovy, Zepbound, Mounjaro. If you are on any of those and having side effects and like, you know what, just forget about it. I feel miserable. I’m sick of feeling miserable before you stop, especially if these medications have been otherwise working really well for you. You’ve been losing weight and feeling pretty good mentally, physically, your body’s responding well with weight loss, but you’re just having some difficult side effects. Let’s talk about those today, so maybe we can keep you on that medication and get those side effects managed. I am Dr. Sarah Stombaugh, board certified obesity medicine physician, and today we are talking about the most common GLP side effects.

We’re going to be focused on side effects like constipation, diarrhea, nausea and reflux, and what are the best things you can do if you are dealing with some of these things so that you can continue on your medication, continue to see the success of the medication that’s been working so well for you. Let’s get into it. So when we think about these medications, particularly today, we’re going to be talking about some of those gastrointestinal side effects. A lot of these results actually because of the way the medication works. When we look at the effect of GLP medication in the body, one of the effects is this slowing down of GI transit time. So if we think, this is kind of gross, but mouth to anus is one long tube and all of that gets slowed down when we are taking GLP medications. So this can create some of those common side effects that you might be experiencing, especially things like nausea, reflux, constipation.

And so one of the magic things is sometimes in managing one of those side effects, we see improvements across other areas as well. Now we think of the effect of nausea. A lot of people will describe this nausea in two different ways. Sometimes it can come up in maybe first thing in the morning or if a long time has passed between meals and this nausea of like, gosh, I am feeling kind of sick to my stomach. I hear a lot of women describe it like morning sickness and they’re like, I’m not sure if eating would make this. Would I feel better? Would I feel worse or not? Always sure there’s that type of nausea. There’s also nausea that comes up after the meal and these can be a little bit different from one another. So let’s talk about that nausea maybe first thing in the morning or when too long of time has passed in between meals.

So this is something to be really mindful of. Sometimes that nausea can be a sign of low blood sugar. It doesn’t mean a dangerous thing, it just mean your body’s saying like, Hey, you should probably be eating something right now. And so you’re getting that kind of queasiness coming up in the morning and when you feel that way, it can be challenging sometimes to actually eat food because the idea of eating a solid is like ugh. I think one of the big challenges or one of the big problems that I see with patients is that sometimes this feels similar to morning sickness or it feels similar to a GI bug. You have gastroenteritis, a stomach flu and you’re like, I should just have saltines. I should have ginger ale. And while those may help you temporarily, they actually set you up for this cycle of not necessarily being helpful.

You’ll see that your blood sugar just is this up and down thing all day long. It also can set you up for just recurrence of those symptoms sometimes like 30 to 60 minutes later when we eat a very simple carbohydrate. So something like soda, ginger ale, Sprite, we have saltines. Those are also a simple carbohydrate. It’s just flour. Basically. Our body processes that for energy really quickly and this can be helpful for nausea in that it can help to relieve that. And we see if we were to put a continuous glucose monitor on your arm and we looked at your blood sugar, we would see that it goes up pretty quickly. The challenge is when you have a simple carbohydrate by itself, there’s no protein, there’s no fat, nothing like that. You see that the blood sugar comes down pretty quickly as well and sometimes comes down to a range that’s below your normal baseline.

So you find yourself in the cycle of this up and down and blood sugar goes up, blood sugar goes down, and when you feel that down, you feel miserable. You feel this kind of crashy hangry, nausea, dizzy, like ugh, it feels totally miserable. So if you want to have something like a saltine or ginger ail, I will allow it, but you do need to make sure to partner it with something that’s going to help last longer. So you want to bring in a protein, you want to bring in a fat so that your blood sugar might go up quickly, but then it’s going to stay elevated for a longer period of time rather than it’s just rapid decrease that could happen. So make sure you partner it particularly with a protein, but even a little bit of fat can be helpful as well for decreasing that risk of blood sugar crash and just kind of riding this nausea up and down cycle all day long.

Now the other thing though is that you’re on a weight loss journey if you’re using these medications. And so every single day or multiple times per day, having a saltine crackers, having ginger ale, that is not going to support you in your weight loss goals. So a lot of times we’ll want to be finding another regimen that helps you feel good but is also going to be more in line with your goals. So particularly for that morning nausea, a lot of times I find this to be a great time to have a protein liquid. This can look like a protein shake, a protein water. This can be something like a yogurt or maybe a really gentle protein like scrambled eggs for example. Something that sits pretty easy in the stomach and doesn’t feel heavy, doesn’t feel like a huge volume. The true liquids can be really helpful.

They move through you a little bit more quickly in a way that it doesn’t feel like it’s sitting heavy in the stomach. Some patients really like there’s a protein water from one of nutrition that is Italian lemon ice flavored. I’ll put a link to that in the show notes below. But this is a really great option because it’s whey protein, it dissolves really nicely in water. It’s got that lemon citrus flavor, which can also be really helpful for nausea. And because of the protein, it’s a liquid, it goes down pretty easily, but it’s not going to set you up for that crashing that can happen later in the day. So if you are like, should I eat? Should I not eat, start with a liquid, particularly something like a protein liquid is one of the best ways you can handle this. Now all of the options I’ve mentioned so far are sweet.
And so if you’re interested in more of a savory profile, something like a chicken bone broth can be a really nice option as well. That in and of itself does have some protein in it. You may even mix a little bit of additional protein, so like a collagen peptides or a whey protein powder, you could mix into your bone broth just to give it a little bit of extra protein. You could put a little bit of salt in there. Do not have an unflavored or an unsalted bone broth. That sounds pretty gross to me. Put a little salt in that will help too with holding onto that fluid help with your hydration status, which can also reduce nausea. So make sure there is a little bit of salt in it unless you’ve been told to avoid salt by your doctor, definitely follow their advice and not the advice of a YouTube doctor who is not your own personal physician.

But that could be really helpful, especially if you’re interested in that more savory profile. But starting the day out with something in your stomach, even if it is one of those protein shakes, protein waters, something like that can be a really great way to reduce the nausea so that nausea that’s coming up in the morning like, Ugh, should I eat, should I not eat? The second type of nausea that we’re talking about is the nausea that comes after a meals and usually this will come from overeating. Now there’s a major air quotes there when we think about overeating because one of the things that happens with the GLP medications is that they decrease hunger and they increase satiety or that fullness signal that happens in our body. And what can be really challenging, especially when you first start the medication or as you escalate the dose of medication, is that that feeling of fullness can come up really pretty quickly and sometimes it’s not a huge amount of food that creates that feeling of, oh my gosh, I really ate too much right now.

And so if you finish a meal and 2030 minutes goes by and you’re like, oh, I really feel like I overdid it, that is a sign that you need to decrease the amount of food that you’re eating. And again, especially at the beginning of your journey or if you’ve increased your dose, it may not be a huge amount of food that creates that feeling. And so be really mindful if your body says it’s full, you should stop. You’re going to have another eating opportunity later. But eating too much in anyone serving can really increase that risk of nausea and over fullness that can happen after meals. The other thing to be mindful of here is the type of foods that you’re eating. The macronutrient breakdown of foods can also create some side effects. So particularly foods that are fatty. Now, if you’ve known me for any length of time, you know that I think fats are an incredibly important part of the diet and we do want to be mindful that they’re balanced with other whole grains with proteins so that we don’t have too high of a fat load on these medications, particularly with the tirzepatide products, I found so Zepbound and Mounjaro, but honestly this will be true for any of the GLP medications.

So Ozempic, Wegovy as well. Those are glides that having too much fat in a meal can really sit heavy in the stomach and can create a lot of those GI side effects afterwards. So this can look like nausea. This can look like reflux, which might be heartburn. It might also be like that acid taste coming up in your mouth. It might be burping or belching after a meal, which can be really unpleasant. You can sometimes taste the flavor of the undigested food sitting in your stomach. Sorry to get kind graphic, but if you know that is a really miserable thing when that comes up. And so being mindful of the fat content of meals will be important as well. Now of course, a lot of times our mind jumps to the greasy and fried foods, things like cheeseburgers or french fries or pizza or chicken tenders.
And while certainly those can create side effects, we also want to be mindful of healthy fats. So even things like salmon and avocado and olive oil, and especially if you’re having a lot of those things together, they may also worsen symptoms. And so just be really mindful of what is the fat content of this meal. You may choose to have a smaller portion of that and bring alongside a fruit, a vegetable, another whole grain protein if you’re not talking about a major protein source so that it doesn’t have too high of a fat load at any one meal, that can definitely worsen nausea, reflex, burping, belching. It can also worsen diarrhea. So just be mindful of that. And with these tricks, most people will find that their nausea can be pretty well managed. Now, one of the things we’ll talk about later in the video is are you on too high of a dose of medication?

Because this is also a major risk factor for any side effects and for having uncontrolled side effects of any type. And so stay tuned as we talk about that in just a couple of minutes. Before we get to that though, I want to talk about constipation and a little bit about diarrhea as well. So constipation is definitely the more common of the two lower GI side effects. There are some people who have diarrhea, we’ll talk about that in just a moment. So constipation, we talked about at the beginning of this video that one of the effects of the GLP medication is that from mouth to anus, it’s one long tube, there’s a slower GI transit time, and because of that, that can contribute to things like constipation. There can be other things as well in that we might be eating less food. So if your stool is passing easily and it’s just a smaller volume, that’s not necessarily a problem.

If you’re eating less, there’ll be less food substance in the gastrointestinal system for your body to pass out. But what a lot of people find is that they’re both going less frequently and then when they are going that the stool can be hard, it can be difficult to pass out. Maybe there’s a history of hemorroids or fissure or something that can worsen during this time, and we certainly do not want to create any new health problems because you’re sitting and straining and having difficult, painful, uncomfortable bowel movements to pass. So from a constipation standpoint, what I will have almost every single patient do is think about a fiber supplement. The reason that I love fiber is that it can be a really good tool both for constipation but actually for supporting diarrhea as well. So particularly as you’re starting the medication, and if you’re not sure if you’ll have either of those two side effects, it can be good because it’s not going to tip you into either category.

It can just be supportive of those. Fiber can be also helpful with supporting satiety or that fullness. It can come up with meals and before you say, well, shouldn’t I just be getting my fiber from food? Totally, that is the end goal that we’ll be able to get your fiber from food sources. But one of the things that commonly comes up, especially early in the GLP journey is that you’re not able to adequately get the fiber from food sources because that volume of food simply feels like too much. And so the idea of eating like an entree salad for example, feels like a lot to put into your body and you’re not quite ready to do that. And so you may be looking to taking a fiber supplement. Now, there’s quite a few different fiber supplements out there, and I will let you choose the one that you prefer, but let me give you some of my opinions on it.

The brand name Metamucil is very popular. Regular Metamucil, however has sugar in it. And as far as I’m concerned, that’s just a really silly way to get your sugar if you want to get sugar in your diet. If you’re on a weight loss journey, get your sugar in the form of a really delicious pastry or cookie or something that you’re really going to enjoy. Getting it in your daily Metamucil, it’s kind of a waste of calories. There is a sugar-free Metamucil, and you can certainly choose this. This is an aspartame based product, and so if you were trying to limit artificial sweeteners in the diet, you definitely want to be mindful that regular sugar-free Metamucil contains aspartame, and that may not be line with your goals. Now, one thing I will often have patients do is go to the GI constipation aisle in their pharmacy, and typically right next to Metamucil will be generic cilium husk.

There’s going to be generic Metamucil as well like orange flavored and everything, but there’s typically an unflavored, plain cilium husk. This can be a really nice option because it’s entirely plant derived. It dissolves nicely into water. It does have a little bit of a flavor, but it’s not flavored. It’s just you might taste it if you dissolve it into water, but really a nice tool for supporting constipation from the standpoint it provides some soft bulk to the stool can help bring water in, especially if you’re having a really high protein diet, you might find that your body is not having a lot of bulk to help produce a nice soft, large bowel movement think will be helpful from that constipation standpoint. It also could be helpful from a diarrhea standpoint is that it provides that same bulk to actually absorb some of the liquid that’s in the gastrointestinal system, in the colon so that when you are having bowel movements, it’s not just pure liquidy, but there’s a little bulk to it as well.

So I really like generic cilium husk. A lot of people will also choose things like Benefiber, which is a great choice, but honestly, choose the one you prefer. Metamucil does make a capsule, and so I have a lot of patients who really like that. The key to taking the Metamucil capsule is you do want to take it with plenty of water. Taking fiber without enough water can actually create a boulder of fiber in your GI system, which is not a good idea either. So if you are taking the capsules, do just make sure to take it with a full glass of water. The only exception there is if you’ve been having a lot of liquidy diarrhea, you might take it with a smaller amount of water, but talk to your own doctor about that being the case and if that is the right thing for you.

But fiber, phenomenal, phenomenal tool. So I actually have every single patient start on fiber as a supplement, and then if they need additional laxatives or stool softeners, we can layer those on as needed. There’s a lot of different ones on the market and different people will respond differently to different ones or feel like they have their own preference. So if you have one in your medicine cabinet, I would start with that. Lots of great options out there. MiraLax is one, Sena is another one. Medications, supplements like magnesium can be really supportive as well. The nice thing about all three of those is they work differently from one another, so you can even layer them on top of each other as you need to. But I would just pay really close attention to your bowels. Are you going regularly when you go? Is it easy and soft to pass?
And if not, try layering on certainly fiber that some of these other supplements as well just to keep things moving. Now, if you’re having used to have bowel movements, let’s say every day, and now it’s every two to three days, but when you go, it’s easy to pass. There’s no problems. That’s not a concern as long as it stays with that trajectory. What we don’t want to happen is that your bowel movements are becoming further and further apart when you are having them. It’s like passing a rock. I don’t want anything like that to happen. So just pay close attention, stay on top of it. Now, if you are someone on the other end of the spectrum that’s having diarrhea. Now, certainly this is more common with the Zepbound, Mounjaro medications, which are tirzepatide products, but can also happen on the semaglutide medications like Ozempic and Wegovy.

Now, we talked about fiber as a great tool both for constipation and for diarrhea. So certainly you can utilize that, but you might find you need something else as well. So thinking about the content of your food, as we were talking about earlier, sometimes having a heavy fat load can be really bothersome to the gastrointestinal system and create worsening diarrhea or create episodes of diarrhea. So being mindful of that can be helpful sometimes too, having simple carbohydrates, so sugar predominantly, but flour really on an empty stomach can also create diarrhea. So just pay attention. Okay, is there a big fat load that’s coming in my diet? Is there a lot of sugar that’s coming in my diet? If either one of those are happening now, we’ll talk about nutrition at another point, but if either one of those are happening from a diarrhea standpoint, it’s probably worth to be mindful of that and think of creating a more balanced meal so that you’re not going to trigger that GI discomfort that can come up.
You can certainly consider medications like Imodium, for example. Do read the instructions on the bottle. If you’re finding that you’re needing it long-term, definitely reach out to your physician because that is not a good long-term solution, but maybe effective as you’re first starting the medication for a couple of doses. Now, we think one of the most important things with any of these side effects is what dose of medication are you taking? One of the biggest challenges that I see when people are reaching out to me and asking about questions is that they have been brought to a dose of medication that is really too high for their needs. We’re going to have an entire video when we talk about choosing the right dose of medication. But what is absolutely true is that you want to make sure that your side effects are well managed before you move to the next dose of medication.

So when we’re talking about medications like Zepbound, for example, this medication is FDA-approved for the treatment of obesity. It’s approved at the five milligram, 10 milligram and 15 milligram doses as long-term use the intermediate doses, the 2.5, 7.5, 12.5, these are designed as titration doses of medication. Now, anyone with logic can say, okay, what’s wrong with taking a 7.5 dose long-term? Well, nothing if that’s the dose that’s working well for you, your side effects are well managed. Excellent. Sometimes though people do run into situations, particularly when they have insurance coverage of the medication that their insurance company will say, okay, you’re on a titration dose of the medication. You need to move to a treatment dose of medication, so you need to take that five or 10 milligram dose. It’s inappropriate to stay on a 7.5 milligram. If you find yourself in that situation, this has a patient one of the most important times to advocate for yourself.
If listening to this, you are a prescriber of these medications, listen up because you can actually request a quantity limit override, basically asking the insurance company to allow you to continue to refill at that titration dose of medication, moving to the next dose of medication before you’re ready, particularly if your side effects are significant, that is not a good idea. You want to make sure your side effects are fully managed before you consider titrating to the next dose. Now, you still, even if your side effects are well managed, that still may not mean it’s time to move to the next dose, but you certainly do not want to increase to the next dose of medication before your side effects are properly managed at your current dose. So this is where it’s really important to discuss with your prescribing physician, you or someone who is getting these medications from a, let’s say, online provider or from a practice where you feel like you are not getting a lot of support, I will recommend for you to see someone who’s going to provide you that support.

There are private practices that focus on obesity. Medicine, doesn’t even have to be a private practice, but someone who is board certified in obesity medicine, someone who is used to prescribing these medications, even if it is your primary care physician, for example, who’s prescribing these, that’s excellent. You just want to know that you have someone who’s going to listen to your concerns, who’s going to help you to stay on the correct dose of medication and isn’t going to push you to the next dose of medication too quickly. That is one of the major things that I see happen. I also see a lot of people who they’re getting a medication from an online program, and when they have a side effect, they’re just told, oh, follow up with your regular doctor, and that’s not always a great solution. So if you’re looking for more support, making sure to see a board certified obesity medicine physician is one of the best ways to do that.

Also, follow me on the GLP guide. I have an online program designed for patients who are starting these GLP medications to work through some of the different side effects to navigate some of the challenges that come up. So much amazing content there that is in a format that’s easy to consume so that you are able to get the support online when you need it. So definitely check out the GLP guide. If you are based in Charlottesville, Virginia, I’d love to see you in person. I also see patients throughout the states of Illinois, Tennessee, and Virginia by telemedicine. So you can contact me at www.sarahstombaughmd.com to learn more and get started today. Thank you for joining us for today’s episode. We’ll see you all next time.