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 to sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today’s episode. This is Dr. Sarah 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 thinking outside of the box, what it looks like to take a comprehensive approach to your weight loss journey. And in a lot of ways today, we are going to be talking about what it looks like to work with an obesity medicine physician. What is a comprehensive approach when you are working on your weight goals? How are you going to do that in a way that feels good for your body that feels sustainable, where you're working on all of those pieces and getting the support across of those different areas. So today we're going to go into that in depth and talk a little bit too, even with the medications, for example, why those are such an important piece of the puzzle for many and they are important, simply that a piece of the puzzle. So they will not even be the whole picture, which is, I feel like sometimes how, especially the obesity medicines, as we're talking about the Wegovys and the Zepbounds, for example, sometimes people are looking at those as the whole shebang. But how do we make sure that people are getting the support and care that they deserve? Now, before we dive into today's episode, I would love to invite you to be a Virginia, where I am licensed to practice medicine. I see patients by telemedicine throughout those states. I also see patients in person in Charlottesville, Virginia, and I would love to have you as a patient in my practice. So if you've been listening for a while, if you've been thinking, oh my goodness, I would love to see her as my doctor. And if you are in one of those states, I would be so honored to be your doctor and to support you in this journey. We are enrolling new patients now. And if you're interested in learning more, we'll put all of our information in the show notes, but you can go to www.sarahstombaumd.com to learn more about me, learn more about the practice. Now, if you are not in one of those states and you are like, darn, I wish that I had a way to work with her, my best recommendation, especially if you're taking a GLP medication, Ozempic, Wegovy, Zepbound, Mounjaro, maybe semaglutide or tirzepatide, so many different ones out there. We do have a course called The GLP Guide, and this is an amazing resource for people who are using GLP medications to address the common questions that they have, whether that's how to travel with the medication, how to utilize their pen, how to manage common side effects, what you should be looking for in terms of protein or other nutrition recommendations. We have some different protein shakes and bar recommendations, for example. And our goal is to put everything that every question you would have into one place for just a simple solution so that you can get answers that you trust, that are evidence-based and not just the next random thing you're seeing on social media, for example. I think the best part about The GLP Guide is that if you have questions that we have not addressed, I would be so happy to create content specifically for you. And so if you have purchased The GLP Guide, you're reviewing it and you're like, oh my goodness, I cannot believe she doesn't have a video on X, Y, Z, fill in the blank topic, send us an email info at sarahstombaumd.com and we will get that content recorded and added to the guide for you and for everybody else who is a member of that course. So excellent. Thank you so much for joining me today. I may have to clear my throat occasionally, so we'll see how this episode goes. But I wanted to, this episode was in my brain and I was just dying to share it with you all. So as we're thinking about what does it look like to support your weight loss goals in a comprehensive way? Now, certainly there may be other physicians who are helpful in this arena. We've learned a lot about integrative medicine or functional medicine or lifestyle medicine. For example, today we're really going to be focused on obesity medicine, someone who is trained and board certified in obesity medicine. What does that look like and what can you expect in your approach? Because one of the biggest challenges with our weight is that our society even still has so much weight stigma and bias, and we see this continue to infiltrate into how we support patients with their weight loss goals. And so recognizing that there is a complex interplay of everything from our biology. So what are our genes? What does our family history look like? Are there other health conditions that we're dealing with? Either those conditions themselves, or sometimes the treatment for those health conditions that can make it really challenging or different for our bodies to lose weight, or even factors like arthritis, for example, where our bodies are not able to move in the way that we desire. And there can be this chicken and the egg effect where you may have severe arthritis, which keeps you from being able to move in the way that you want to. But then as a result of that, you're seeing that you may gain more weight. which may worsen the arthritis and may also further limit movement. So you see these biological genetic family effects. There's also so many effects in terms of our environment, recognizing that we live in an environment where healthy food choices are not always available. People may not have access to those even if they are available. There may be limiting factors like schedules or time commitments, for example, that people do not always have access to. access to the choices they want. There's other examples as we're thinking about, you know, what does your sleep look like? You know, there's this interplay of the underlying conditions. We've got nutrition, we've got movement, we've got other health conditions. And what about sleep? I encounter so many people who are having challenges with their sleep. And I was actually having a conversation with someone the other day about hormone replacement therapy. And they were saying to me, oh, I'm surprised that you prescribe hormone replacement therapy for your patients. And I was like, well, think about it. If someone, the patient about whom we were talking was having severe hot flashes, she was unable to sleep through the night, and we were looking at layering on evidence-based estrogen and progesterone hormone replacement therapy for this patient, and it was life-changing for her. For the first time in many years, she was actually sleeping through the night. She was not having hot sweats. And so that is something that when we're looking at the whole person we're able to see things like okay they are not sleeping well and we need to make sure to address that so that might look like diagnosis of an underlying sleep condition like sleep apnea conditions like insomnia treatment for those conditions maybe there are external factors like in perimenopause and menopausal patients with hot flashes for example maybe there are patients whether it's male or female who are waking up many times throughout the night as a result And so maybe we're addressing those pieces. And so even though the goal is to support someone with their weight, we end up working on all of these other areas as well. Very commonly, I will talk to patients who have been prescribed other medications that have created a lot of weight gain for them. And this can be a challenging balance to strike because there are some medications that even though we know weight gain can be a profound side effect, it may be life-changing or life-saving that they have to be on these medications. So most commonly, the medications that are known to create significant weight gain are medications like steroids. So chronic prednisone or chronic steroids that are used for certain health conditions, maybe for immune system if you are going through cancer therapy and suppressing and supporting that, sometimes also for chronic rheumatological conditions like certain inflammatory arthritis disease, for example. Although if you are using chronic steroids for conditions like that, I'll encourage you to see a rheumatologist because over the last decade we have seen so much evolution in that space in terms of managing and supporting patients with chronic inflammatory diseases. But there are certainly patients for whom they've needed to take some of these medications long-term or they've cycled on and off of them long-term and medications like that can have a really profound effect on weight. There's also medications like antipsychotics, for example, and these are again, life-changing, life-saving medications. And for many patients, I may be working closely with their psychiatrist to see if there is room to adjust these across the whole category of antipsychotic medications. There are some medications that are more or likely to create weight gain effect compared to others but we also most importantly is making sure that we're keeping someone safe that we're keeping them alive but also that we're keeping them healthy and so if there's room for adjustment can we do that because certainly we encounter patients for whom they've had a 50 or 100 pound or 200 pound weight gain and that of course ends up having other challenges in their health and so alongside starting medications where we know that there'll be weight gain, or we know that there's a severe metabolic impact of certain types of medications, we're often recommending very early on to use other medications, whether that's things like metformin, which is a medication commonly used in the treatment of type 2 diabetes, or whether that is some of the GLP medications like Wegovy and Zepbound, in order to really support these patients to minimize that impact of medication. So those, whether we're talking about prednisone and chronic steroids, whether we're talking about antipsychotics. Those are more significant examples. What we see really commonly though is medications like SSRIs. So these are medications used for the treatment of anxiety and depression. You would recognize some of them, probably medications like Zoloft, Lexapro, Prozac. There's a whole host of other ones out there. But these are medications that are very commonly used, sometimes in an intermediate fashion, six to 12 months, other times in a long-term fashion, and have phenomenal safety data in the treatment of conditions like anxiety and depression with these medications. But when it the things that can be really challenging is that across this class of medications, there are ones that are more likely to be weight positive, meaning that they create weight gain, ones that may be more weight neutral, and then less commonly, unfortunately, ones that may be more likely to create weight loss. What will be most important though, is talking to an individual about what their history was, especially when they started that medication. I very commonly hear stories of, I started a medication and I had a 10 pound or 20 pound weight gain. And if you have that clear history of having started a medication and having had a weight gain after it, it's not always as clear and simple as that. But a lot of times we are able to make a transition to a different medication in the same class. So a medication that's designed to do the same thing. And for most people, we find honestly ends up having the exact same effect where we're they find that their anxiety symptoms, their depression symptoms are perfectly adequately supported with a new dose of medication or with a new medication while not having that propensity for weight gain that maybe their previous medication did. So we're looking at these other factors in terms of other health conditions, maybe diagnosing those, whether it's the sleep disorders, which are very commonly undiagnosed, maybe it's just making adjustments to the treatment plan. And I will do that sometimes on my own, but certainly in combination with other physicians on someone's care team, if someone else has been prescribing, and especially if they've had a really challenging journey there, but recognizing that there are these other places that play a role. Now, one of the things that I think is really interesting is that when we look at the data for the anti-obesity medications or the obesity management medications, so these are things like Wegovy and Zepbound, those GLP medications that you hear about all the time These also encompass older medications like Saxenda, Contrave, which is a combination of bupropion and naltrexone, Qsymia, which is a combination of phentermine and topiramate. Topiramate by itself would also be in this category. I will often also prescribe individual components from some of those different medications. So thinking about topiramate, thinking about phentermine, thinking about Bupropion, naltrexone, metformin is a medication that's not actually approved for the treatment of obesity, but we do know has weight loss effects commonly with this medication. So it's a medication I use frequently for patients. But when we look at, honestly, even the whole spectrum of medication, when you look at what is the average weight loss in on the clinical studies, for example, versus what is happening in a real life practice, I think this can be really telling as well to what is the complex condition that is chronic excess weight, which is metabolic disease. And then are there other pieces that we can pull together in order to support someone in losing maybe above and beyond what is expected on the averages? So what's most fascinating is with the GLP medications in particular. So when we're talking about Zepbound, we're talking about Wegovy. These medications, if you look at the clinical trials, on average, Wegovy creates about 15% total body weight loss over a year or a little bit more. And the Zepbound medication, depending on the dose that you're on, creates about 20% over the course of a year, a little bit more than a year. And so when we look at these numbers and we look at what does that mean in real life, it's These numbers do not always align with someone's goals of weight loss or honestly, sometimes even the amount of weight that they would want to lose in order to change and impact other health conditions. So if we imagine someone who lives in a 200-pound body, for example, and we're talking about losing 15% of their total body weight, that is losing 30 pounds. So they started at 200, they're ending at 170. That may mean for someone who's taking a Zepon medication, and we're talking about losing 20% of their body weight on average, They started at 200 pounds. That would be on average a 40 pound weight loss, bringing their weight down to 160 pounds. And depending on their goals, depending if they are male or female, depending on your height. So our height has so much to do, of course, with what our body weight should be. You know, when we think about our frame, someone who is five foot tall is going to weigh a very different amount from someone who is six foot tall and certainly everything in between and beyond. But when we look at what are our goals, are those numbers going to be adequate for treatment? Similarly, if someone was starting at a 300 pound body size and lost 15% of their total body weight, that would be 45 pounds. So a weight reduction of 45 pounds would bring that person down to 255. We're starting at 300 pounds and a 20% reduction would bring someone's weight down 60 pounds on average, bringing them down to 240 pounds. And so when we are looking at weight loss goals, this is often a question people will have early in the journey. And I think I give a probably what is infuriating to most of my patients of we'll know it when we get there. So when we look at the response that people have to medications, whether it is Zepbound or Wegovy, or whether it is some of the older medications that I mentioned, the response to that medication is going to be dependent on a lot of factors. There are some people for whom almost unpredictably are super responders to this medication. I have had some people who do phenomenally on this medication and lose 40 or 50% of their total body weight, where other people barely respond at all to these medications. So there is a really broad variation in what the response will look like. And some people are going to have different responses than others. But there are pieces of it that have become more predictable as we've been treating more and more patients with these medications and understanding, are there things that can predict who will be more responsive? So when we look at metabolic disease, when we look at how long has someone been dealing with elevated blood sugar levels, elevated insulin levels, maybe an elevated hemoglobin A1C, like prediabetes or even diabetes, how long have they been dealing with their chronic excess weight? Is it something that came in over the last five years or is it something that they've been dealing with for five decades? The answers to those questions very commonly will correlate with someone's responsiveness. So who has less weight to lose or has held their weight for a shorter period of time may be more responsive to these medications compared to someone who has had their weight for a longer period of time or has more weight to lose. Now, of course, that is an overgeneralization, but those can be certain factors that we will predict. But what can be really interesting is that when we pull in those other pieces, when we're talking to people about nutritional changes, When we're thinking about, are there changes we can make to make sure that they're getting adequate protein, to make sure that they're getting adequate fiber, that they're paying attention to what are the foods that are creating the feeling of fullness in their body and leaning into those type of food choices. When we are encouraging people to move their bodies regularly, and this is going to look like we start with where you're at. So someone who has not been able to be physically active because of limitations, this may look like a on a bike, for example, this may look like let's pause on exercise while you lose weight and we start to incorporate exercise in at a later point as maybe their joints are feeling better. Their body's feeling lighter and they're able to move more readily. So it may be something that we bring in much later in the journey, and that's not always expected. Some people are excited to start at day one or already feeling shame or frustration because on day one, they know they're not going to be able to start an exercise program that they would have liked to be able to do, but they have physical limitations that keep them from doing that. So that can be really empowering to say, hey, that may be an important part of your journey, but that may come in six months, for example. as you've lost weight, maybe as you've had a joint replacement surgery, whatever that journey looks like for the individual. This looks like understanding and diagnosing those other health conditions. So as we were talking about, are there things going on with sleep, for example? Are there things going on with the treatment of other medical conditions for which we need to be adjusting or supporting with different medications? When we look at behavioral factors, understanding both our environment, human habits, what are the different cues in our environment, the things that trigger us to move forward with eating outside of our goals, things like emotional eating, but even recognizing that for many patients who've struggled with their weight, there's a deeper underlying psychology there wrapped up in maybe trauma, shame, or guilt from weight cycles that have happened in the past where we've lost weight and gained weight and lost weight and gained weight. And that can be really discouraging. And so starting out on a journey, it's like, oh, is this going to be just like all of the ones that have come before it? And of course you would feel that way. I mean, that's your human brain protecting you from what has been... probably really challenging situations in the past and almost protecting yourself from that heartbreak that can come up. And so working through that with the support of either an experienced obesity medicine physician who's used to supporting patients in that way, but a lot of times we may be bringing in a health psychologist, for example, to make sure that people have that support in their journey. And so thinking about what are the reasons behind our eating choices? Are we reconnecting with our body, paying attention to what is our hunger? What is our fullness? Learning about the foods that are going to best create that for us, really intentionally deciding how to incorporate in foods that may not traditionally be part of a quote unquote healthy food plan. And so I know I'm familiar with a lot of programs, for example, that take really extreme approaches to new nutrition, whether it's a keto diet or a carnivore diet or no sugar, no flour, those are really powerful tools and they absolutely work. And what I'm doing with patients is trying to teach them, how do we incorporate in foods that may not traditionally be on a dietary plan? How do we incorporate those in, in a way that you feel in control? Because if you have decided that every time that I eat a donut, for example, that I feel out of control. I end up eating two or three donuts, then I'm craving them and thinking about them all the time. That is not a lifelong relationship that you want to have with donuts. So you may decide that I have zero of these and I just, I don't even go there. And that is a choice and that is an option. But for most people, they will realize, you know, I'd actually love to reestablish this relationship with donuts where it doesn't create all sorts of additional cravings for me, for example. If that sounds like a theoretical example, I will tell you that that is absolutely possible. It takes time though, and it takes learning and practicing self-compassion. A lot of times we are working together, patient and I, to review situations that did not go according to plan and workshop those. How could we do that differently next time? How could we, as you look forward over an upcoming vacation or just an upcoming challenging time at work or challenging time at life, how can you make a plan that's going to be most supportive? When we get to use that curiosity, when we get to have compassion for ourselves and for our journey, you can start to reshape some of those behaviors and then reestablish that relationship with yourself, building the self-confidence to feel like, hey, I know what's best for my body and I get to make that choice. Now, certainly medications are often part of that journey because especially when we've been dealing with chronic excess weight there is underlying metabolic disease for which these medications can be phenomenally supportive and when we combine those with all of those other pieces the nutrition the movement the sleep the stress the emotional eating understanding all those behavioral pieces together it is amazing to see the effect that it ends up having in someone's life and I am so honored to support people alongside that journey and just watch their life turn completely around, feeling like they are able to move, that they feel reconnected with their bodies. And it's amazing, absolutely amazing to be able to do that. And so this may look like a lot of pieces, but if you've been listening to this and you're like, oh my gosh, that is what I need in my life. The best thing to look for is someone who is an obesity medicine certified physician. Now, there are some people for whom they have done some additional attended a conference and done some additional training and sat for the exam and people who practice this in a broad spectrum of ways. Looking for someone who is certified in obesity medicine is going to be an amazing tool. The best way to do that is to go to the ABOM, the American Board of Obesity Medicine, and look for a certified obesity medicine physician who is near you, who could see you. One of the things I'll also encourage you to do is get to know that person. Maybe that through social media, maybe they have a podcast, even just looking at their Google reviews, for example, because going into those visits, you want to feel confident that you are getting someone who is going to listen to you, who is going to support you in that comprehensive way. beyond just, you know, here's a prescription for a medication, see in three months, for example. You want someone who's going to support you in that more comprehensive way if that's what you desire for your journey. So with that, we will wrap up today's episode. I hope this has been interesting for you. As always, a lot of the topics we've been addressing recently have been inspired by questions we've been getting from our listeners. I will tell you, it is absolutely my favorite thing when you all send emails to me, send me messages on social media let me know that you've been engaging with the podcast episodes that you've enjoyed things that you're interested in learning more about it is really important to me to respond to those to be able to create content that will be interesting for you and so we've been working through a lot of that recently And so please reach out. I think sometimes people think we get, you know, just hundreds of emails or something. But a lot of people don't take the time to reach out. And so when someone reaches out, I promise you, you will get a personalized response back from me. If you have an episode that you're interested in learning more about, reach out and let me know that as well. We will plan an episode just for you. And you can email us at info@sarahstombaughmd.com in order to communicate that to us. Thank you so much for joining us for today's episode. We'll see you all next time. Bye-bye.