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 on your GLP journey for any amount of time and maybe you are approaching the top dose of medication or maybe you’re at that top dose of medication and it’s been a couple of months, a very common panic that will set into people’s minds is, oh my gosh, I’m on or I’m approaching the top dose of my medication. Is this it? Am I done with my weight loss journey? Am I going to expect to see any more weight loss? I don’t feel like I’m done. I know I want to lose more weight and yet I feel like I’ve reached the end of my rope. So if you have had those thoughts or maybe you’re just hearing me say this for the first time and you’re like, thank you so much for introducing this new anxiety into my head, Dr. Stombaugh, let’s talk about this today because I want you to know that there are options and just because you are at the top dose of your GLP medication does not mean that you have to be done with your weight loss journey.

I’m Dr. Sarah Stombaugh, board certified obesity medicine physician and it is my goal to help support people in a comprehensive way with their weight loss journey and that often includes GLP medications. When we think about the GLP medications, the ones that we’re thinking about most frequently are Wegovy and Zepbound, but we’ve seen a lot of new players coming onto the market like the Wegovy pill. Most recently we saw Foundayo being FDA-approved. If you’re interested in learning more about any of those specifically, definitely check out my videos where I talk about those other medications. What are the results that we can anticipate? What’s the difference of taking an injection versus taking an oral pill? We have a lot of different options available. Now, the reason today we’re going to focus a little bit more on Zepbound and Wegovy is that these are the two most potent GLP medications for weight loss.
At least at this time there are medications coming down the pike and we’ll talk about that in the end of the program too. So stay tuned if you want to hear about some of those medications that we can expect in the future. But right now we’ve got Zepbound, we’ve got Wegovy. Now what’s interesting is that Wegovy previously has been available in five doses 0.25, 0.5, 1.0, 1.7, 2.4. It was just recently that Wegovy high dose was released at the 7.2 milligram dose. So there is now a higher option available for that. We do have a specific video that addresses that and a little bit about the data of that medication. On the other hand, we have the Zepbound medication that’s available also in six doses, 2.5 milligrams, five milligrams, 7.5 milligrams, 10 milligrams, 12.5 milligrams, and 15 milligrams. And the reality is when we look at the data from the trials of Wegovy 7.2, when we look at the data from Zepbound 15, they’re pretty equivalent in terms of creating about 21% total body weight loss.

So one of the things that I’m thinking about from the very beginning of someone’s journey is what is their weight right now? What have weight loss attempts looked like in the past, whether they’ve used medications or not? How significant is their metabolic disease? So are we seeing other things like elevated blood sugar, prediabetes, diabetes, signs that your body may be more insulin resistant? Sometimes weight loss may not be as easy for that patient population. Again, not impossible, but there’s just other considerations that we’re having. We’re thinking about, okay, what amount of body weight does someone need to lose? We have really good data that’s showing that a lot of times 10 or 15% total body weight loss can dramatically improve blood pressure, cholesterol, diabetes, these health conditions that are often associated with weight. So while sometimes on social media, we see people losing 20, 30, 40, 50% of their total body weight and that is awesome for those people.
The question becomes, how much weight do I or the patient in front of you, how much weight do you really need to lose? Now sometimes an answer that I give my patients that drives them a little bananas is we know it when we get there. So we talk about what are the average anticipated weight loss from these medications. So on average, patients in these clinical trials lost about 20% of their total body weight. Now what’s true is that you are not an average patient, you are an individual. So when we look at the waterfall plot, we say, okay, what happened to all the people who lost none of their weight despite taking a high dose of medication, who lost even more of their weight? There’s a really broad distribution in response and you could be any single one of those data points. Now we do have some things that we’ll predict who is more likely to lose more weight.

So for example, as I was saying, people who have less metabolic disease, so people who do not have type two diabetes, for example, maybe even someone that doesn’t have prediabetes, for example, the amount of time that they’ve struggled with their weight, there’s a lot of different things that can help us predict who will or will not be more responsive to these medications, but we can look at, okay, what is the anticipated response to this medication and then how do we help you as you’re on this journey? So I think that GLPs are used in a most amazing way when they become the tool that allows everything to click in the way that you’ve been working on. So the nutrition changes you’ve been trying to make, the exercise, the stress management and how we think about our food and make choices around the food that we’re making.
When we work through all those pieces alongside the GLP medication, it is very common in my practice that I see patients who are losing some of those more significant body weight numbers, 20, 25%, 30% and beyond, which is so, so incredible. But what happens even if you’ve lost 30% of your body weight, for example, if really you need to lose 40% of your body weight or 50% of your body weight? Now we can question, does GLP medication make the most sense versus are you someone who’s a better candidate for bariatric surgery or even both of these two things together? A lot of people though are coming into my practice because they’re like, “You know what? I really don’t want to have to have bariatric surgery if I don’t need to. Can I trial medications first?” And the answer to that is absolutely yes. So everybody should start on the lowest doses of medication and then over time we’re titrating based on a few things.

What is your response to medication? So are we seeing movement on the scale? How’s it feeling in your body? So in terms of how the effectiveness is, what is your hunger? What are your cravings like? What is your food noise like? What are the side effects? Are you having significant side effects from this medication? Ones that we definitely want to make sure we’re addressing and managing before we move to the next dose of medication. So really the quickest we would move through all the doses of medication would be within six months, very commonly in my practice. So it may take a much longer period of time, even closer to 12 months before we’re reaching those top doses of medication, but it’s really going to be based on the patient in front of me. So when I say that to say we’re thinking about, okay, you’re like, I’m at the max dose.

But if you can start from the beginning, if you were before that point and thinking about, let me really intentionally manage my dosing of medication, manage that titration in a very slow and intentional way, that can make a huge difference as well. Because one of the biggest challenges we find is that when people are very aggressively titrated through these medications is that we may not be able to appropriately support the other lifestyle pieces that can drive long-term weight loss success. So what that looks like is are we supporting your muscle mass? You hear about this a lot thinking about, “Hey, am I maintaining or even building my muscle mass during the weight wash journey?” In order to do that, that is going to require adequate protein intake and that is going to require regular exercise, particularly resistance training. As we are increasing our muscle mass, that will improve our metabolic health.

So what this means is that we’re going throughout the titration. I do not want my patient to be eating nothing. It is a major red flag to me when someone says to me like, “Oh, I just haven’t felt like eating anything at all. ” Or sometimes they’ll have consults from patients who’ve been starting all those medications in outside clinics and they’re like, “I just feel so sick all the time. I just sip on some broth or have a couple of crackers.” That is not the goal of these medications. The goal of these medications is allowing you to eat in line with your goals so that you are not feeling overly hungry, so that you’re not having significant cravings and that you are able to really fuel and nourish your body. Over time, as we’re titrating these medications up, if you’re able to eat foods that feel really good and fuel your body, you’re getting that adequate protein, you’re getting exercise and feeling strong and energized enough to be able to do that.

Now when you’re at the point where you’re at the maximum dose, we all along have also been working on supporting and building your muscle mass, which is going to have a huge impact on your metabolic health. We know that muscle is one of the ways or really the best way that our body can utilize blood glucose and it uses it in a insulin independent way. So our body can process that blood glucose in a very effective way and this can really be one of the great tools for reducing insulin resistance. So as we’re getting to some of that top dose of medication, it’s at that point that we’re not just saying like, “Hey, let’s all add in all this stuff right now.” You’ve been doing that stuff all along. And so we feel like we’ve been building your muscle. There’s been other pieces that we’re doing in order to support your body.

Now, even so, you may lose 20% of your body weight. You may be the person who’s just exactly average, or even if you’ve lost that 30%, you are someone who’s looking at, okay, I’m down this amount now, but I’m still maybe having some elevated blood pressure. I’m still noticing that I’m having joint pain. I feel like I have more weight to lose. Do I have to have bariatric surgery right now? Am I done? Is there anything else that I can do? The answer to your question is yes, there are absolutely other things that we can do. This may be lifestyle, this may be other medications, there may be considerations for bariatric surgery in the right patient. So when it comes to a lifestyle, I think one of the most important things to notice is that the GLP medication, even if it does not feel as potent as it did before, and this is very common, you’ve been taking it for a long period of time and you are able to eat, you’re noticing like, “Oh, sometimes I have a little bit of sugar cravings.” It is okay for that to be the experience, but it is still working in your body.

If you do not believe me, if you stop the medication for any reason, you will notice very quickly that that medication was absolutely doing something. Now, please just trust me on this. I would not recommend just stopping the medication to say, “Hey, was this working? Hey, is this doing anything?” Unfortunately, a lot of people have the experience of having to stop the medication maybe because of a surgery, they’re stopping it temporarily for example, or maybe they’ve had some sort of change in insurance coverage and they’ve had to stop the medication. And believe me, even if while you were on it, it was not totally clear that it was working in the same potent way that it may have been months ago. It is absolutely still doing something in your body. So it is still regulating how your body is processing glucose, for example. It is still regulating the way your body’s willing to release fat stores in a way that it may not have been doing previously when you were struggling with more significant insulin resistance.
So even if you notice you’re more hungry and occasionally have some food cravings, it is still doing something and it’s valuable to continue the use of that medication. Now, one thing I will often consider is does it make sense for us to consider other medications for a patient who’s like, “Hey, I have more weight to lose despite being on the top dose of medication.” And the great news is that we have a lot of different medications that can be effective in order to support weight. Now, a lot of the older medications, no one talks about them because they do not have the same potency compared to the GLP medications. But what is absolutely true is that we know that people struggle with their weight for many different reasons, oftentimes a combination of many different reasons. There may be slow metabolism, there may be a slow utilization of energy, there may be significant food hunger, there may be significant cravings and desire in seeking a food.
And depending on which of these you are struggling with, it may make sense for us to layer on an additional medication in order to support you. That may look like things like phentermine, for example. This is an appetite suppressant medication that can be very effective and can be used in combination with GLP medications because it works in a different way compared to the GLPs. So you get to layer on something like phentermine, for example. You can add on something like bupropion. Bupropion is a medication originally thought of for the treatment of depression. It is also branded as Contrave. So bupropion plus naltrexone together are branded as Contrave for the reduction of appetite and cravings. This medication really works on reducing cravings, reducing appetite. It’s been used in other things like smoking cessation, for example, and alcohol cravings. So it’s very common that people who are craving food significantly may benefit from use also of bupropion.

So we could do that alongside their GLP medication. Someone who still has some mild insulin resistance disease may benefit from the addition of something like Metformin. Metformin is a medication commonly used in the treatment of type two diabetes that can be a valuable tool for the patient who still has some level of insulin resistance. We might be thinking about other things like topiramate or brand name Topamax. This is a medication that was initially used for seizures and has this appetite suppressant effect of it. Phentermine plus topiramate are branded together as Qsymia medication, but we can use these individual components. People on topiramate, even if they’re taking it for another reason, so commonly it may be used for migraine, sometimes for chronic pain, sometimes for treatment of anxiety in addition to other antianxiety medications. It is very common that people who are utilizing this medication may not even be thinking about their weight and they come back for their follow-up visit and they’ve lost five or 10 pounds without really meaning to because it does suppress the appetite.
So the patient who’s on the GLP who’s looking for additional support, we could be thinking about any or maybe multiple of these different medications, phentermine, metformin, bupropion, topiramate. There are other medications that can be really good tools. We may also be thinking about, is there anything else health-wise that’s going on? Have we checked your thyroid, for example? Someone who has thyroid disease, their thyroid needs may change as they are progressing in their weight loss journey or new thyroid disease can come up during a weight loss journey. So we want to make sure we’re screening for that. Is someone aging and going through changes of perimenopause or maybe their post-menopausal and feeling that effect of declining hormone levels? Maybe we think about, is there a role for hormonal replacement therapy to support underlying metabolic disease here? We know that low levels of estrogen are a major driver of metabolic disease in post-menopausal women.

And so does it make sense for this patient that we are thinking about estrogen replacement therapy, for example? So thinking about that menopausal hormonal therapy and that can be something that drives us past a plateau and continues to support us beyond just the GLP medication. There may be other tools that we’re using that are over-the-counter non-prescriptions. So I’m a huge fan of fiber and this can be fiber that you’re getting from fruits, from vegetables, from grains in their whole form, but honestly, even fiber supplements. There is data to show that if you have fiber before a meal, so if you have metamucil capsules or a glass of metamucil or plain psyllium husk, for example, BelliWelli, even having a cucumber or a pickle before a meal, that that is going to help fill you up. It is going to help your meal digest more slowly and is going to help so that you don’t feel quite as hungry to eat as large of a volume.
So having something very fiber and liquid rich before your meal is going to be helpful. So can we even use a couple of capsules of metamucil, for example, or capsules? They saw the 3-in-1 metamucil capsules. You could also get a plain psyllium husk or metamucil. Can you mix that into water or take a few capsules with a glass of water, let’s say three capsules with a glass of water before breakfast, before lunch, before dinner to help with regulating appetite if you find that you’re still wanting to eat large volumes of food. Something like that can be a phenomenal tool. There’s really interesting data on certain probiotics, particularly the Akkermansia species. And so can we help someone with a probiotic like Akkermansia, for example, for helping to regulate glucose control and metabolic disease? So really cool data on probiotics. So we might be thinking about fiber or probiotics, these other tools as well.

So we can utilize multiple tools in our toolbox. Of course, we’re always thinking about lifestyle intervention. Is there an area that we can optimize? And it doesn’t have to be everything at once, but anytime that we’re hitting a weight loss plateau feeling like, oh my gosh, am I at the end of the rope? We can start to look at, are there areas that we can improve? Whether that’s getting a better night’s sleep, more quantity or more quality of sleep, whether that’s moving your body more regularly, whether that’s incorporating in resistance training, looking at, am I getting adequate fiber in my food? Am I getting adequate protein? Making sure that we’re looking for anywhere that things could be more in line with your goals. We’re looking at all those different lifestyle pieces. Now one of the amazing things and one of the things I just love about this space right now is that we are seeing an explosion of options of medication.
Even in the last couple of months, I feel like I can barely keep up with the updates for you all because we’ve got new medication after new medication and there are dozens of medications coming down the pike, but some of the ones that we are most excited about are medications like Retitrutide, for example. This is a triple G-receptor agonist targeting GLP, GIP and glucagon receptors. So the Zepbound tirzepatide medication is a double receptor agonist targeting the GLP and GIP receptors where most of the other or all of the other GLP medications on the market are single GLP receptor agonist. So these medications are showing even more potency. We’re really anticipating about 26, 27% total body weight loss for patients taking retatrutide. There’s a medication called CagriSema coming down the pike. So lots of different things that over the next couple of years we are anticipating seeing on the market that may be more potent compared to what is currently available.

So we can utilize what is currently available to us recognizing that there may be move for medication adjustment in the future. I think a lot of people are not super excited about bariatric surgery, but it can be a really good fit in the right patient population. I think one of the questions that people have always considered is GLP therapy or weight loss medications versus weight loss surgery. And the reality is it does not have to be an either or conversation. It can be a both and conversation. So very commonly in the bariatric surgery space now, they’re seeing patients who’ve used GLP medication either before their surgery and have additional weight loss goals or patients who’ve had surgery and are looking for additional weight loss support and may add on GLP medications. So even the person who’s on the GLP doing well on it may also be a candidate for bariatric surgery.

So we’ve got multiple tools then that are supporting our long-term weight health. If you are getting towards the end or you’re getting towards that top dose, you’re at that top dose for a while, just know that it is normal for weight loss to slow down and it is normal for plateaus to happen. Our weight loss journey is rarely linear, which can be so frustrating when we are in the middle of it. But I want you to feel empowered to know your body, to know the way that medications are feeling, to speak with your doctor about what are the options that are available to you. Now, I do see patients in Charlottesville, Virginia, and I would be so honored to be your physician. I am enrolling patients now if you go to www.serastambamd.com. I also see patients by telemedicine throughout the states of Illinois, Tennessee and Virginia.

Now, if you were outside of one of those states and you were looking for additional support, I have an amazing online program called The GLP Guide. It is just $149 for a full year of access to on-demand video questions or video answers to all the questions that you might have about your GLP journey. I am addressing all of the most frequently asked questions so that anything that you have, you are not late in a Google searching or on Reddit or TikTok trying to get the answer to your question. I have the evidence-based answers that you need and if you are on that resource and you have a question and you’re like, “Oh my gosh, Dr. Stombaugh, you do not address the question that I have.” I want you to send that to our team and we will record a video just for you and add it to the platform for your benefit as well as for the benefit of everybody else because my goal is to help you feel supported in your weight loss journey. I’m so excited to have you here on the program today. Thank you for joining me today. I’ll see you all next week.