Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to today's episode. We are talking about a topic that is so, so important and to be honest, I am not sure how, we haven't really addressed this quite yet. We are talking about the earliest signs of metabolic disease. Now, we've talked a lot about sort of related topics. We've talked about insulin resistance and we're going to talk about that more in depth today. But the goal of the conversation today is to give you some very actionable things that you can go back and look at maybe your most recent physical, look at your lab results, look at your weight, look at your blood pressure, look at all the signs of information that you already have in front of you and start to see are there signs of early metabolic disease that perhaps nobody has pointed out to you yet or you haven't really been advised to take particularly seriously. And this is the time when you have those earliest signs of metabolic disease. Reversing metabolic disease is easier early in that illness compared to later on. We'll talk about more what I mean with that as we're diving in. But this is going to be one of those episodes I hope really helps to connect some dots for you. If you have been struggling with your weight and not really understanding why, or maybe even asked your doctor and haven't really gotten good advice as, Hey, why is this number elevated or that number elevated? We are going to talk about some of the routine labs that you get and how do we make some of those changes before it becomes too late. This is one of those episodes that I hope will be applicable to a really broad audience. And so I would love if you could take a moment to share this episode with a friend, with a family member, with someone in your life with whom has been struggling with their health, is looking for a resource to help them. I would love to be able to support them in this. And I think this episode is a great way and like I said, really approachable for a lot of people. So let's dive in and talk about what is metabolic disease. So metabolic disease can take on a lot of different functions, but primarily we are talking about our body not properly using energy, storing energy, burning energy and the accumulation of insulin resistance that can lead to fat mass or leading to insulin resistant conditions like pre-diabetes or type two diabetes. Now, one of the things that happens is in the way our healthcare system is currently set up is there's a lot of let's find the problem once it's there and treat it. We do not always have a preventative approach. Now, there are a lot of things that keep that from being possible, even in terms of how we cover medications, for example, in terms of some of the GLPs, we think about Ozempic, we think about Mounjaro, the versions of the GLP medications that are used for the coverage or used for the treatment rather of type two diabetes. The weight versions of those medications are not always covered. So there's patients for whom they feel like this catch-22 of "Do I have to let things get too full-blown type two diabetes before I have coverage for these medications?" So there's a lot of issues like that where we don't always have good solutions for when we are in the earliest phase, seeing earliest signs of health condition changes, seeing those early insulin resistant things. And honestly, we're not always even talked about how to look at some of those early changes and what are actionable steps that we can take. So most of, I'm a family medicine physician by training. I did my residency in family medicine before doing additional training in obesity medicine. And a big driver for me in even going to medical school and going into primary care was the drive of understanding our metabolism, understanding obesity. I had a lot of personal factors and then later even professional factors in wanting to know and understand this. And it was really frustrating for me in medical school going through four years of medical school, two years in the classroom, two years in the clinics and in the hospital and not getting great answers from a nutritional standpoint, we had a couple of hours of lectures dedicated to how our body dedicated to nutrition, dedicated to how our body utilizes different macronutrients. For example, some of the very earliest stuff in biochemistry we talked about, but not really talking about obesity as a disease standpoint. And I'm young, so I am 37 years old. I graduated from medical school 10 years ago. So if you were listening to this episode when it's live in 2025, it's not like I've been practicing medicine for many, many decades. And what was taught then, it was super outdated. I went to medical school and graduated from medical school 10 years ago. So in my medical school training didn't get a lot of information about metabolic disease even in family medicine residency. I remember early on having patients who were looking for help supporting with their weight loss schools, starting to learn about the treatments that had just been FDA-approved for the treatment of obesity, some of the now what we would consider older medications, but medications like Saxenda, Qsymia, these medications were FDA-approved in the early 2000s. And so it was really exciting going to residency in 2015, we had these three medications available and I would talk to my patients about them. But as a resident, you have to have, especially your early years of residency, you have to have your attending physician sign off on the prescriptions that you're rating, particularly if it's a controlled prescription, which contains phentermine is a controlled prescription. And so I would talk to my attendings, Hey, I'm thinking about doing this medication. I've talked to the patient, these are their risk factors, these are the side effects I'm concerned about. This is why I recommend this medication. And I had a lot of mentors even who basically had me, why is it important to give them a medication for this? Can't we tell them to eat less and move more? And so even in my family medicine residency, not always having the support, not always getting the full answers to how do I support patients with their metabolic disease? And it was only as I learned and study this more throughout my residency and then in practice that I realized a lot of times we are waiting far too late to treat people for their metabolic disease. And what if we could diagnose, what if we could treat this? What if we could support patients early on rather than waiting until things are more progressed and then actually more complicated to treat? So when you're thinking about metabolic disease, the earliest, earliest signs of this we're primarily talking about insulin. We are talking about when our body has a accumulated fat mass, when our body, maybe even before accumulating fat mass, just those earliest signs that your body is not using energy in the way that it is supposed to. Now this is the result of so many factors, whether it is environmental, particularly the foods that we eat are highly processed foods that are available in the American diet right now. Foods that are full of sugar, foods that are full of flour, foods that did not create appropriate satiety or that feeling of fullness can be drivers of having elevated blood sugar levels. Now very early on, well, I will say other things too, like stress for example, we all live in this very stressful environment, not sleeping adequately, can be a major driver of this. Other things as well, like going through hormonal changes of perimenopause or for men as their testosterone levels are lowering, there are other changes that contribute to this as well. And very, very early on there is this sort of silent disease that is progressing. So you may not see many changes in terms of your normal labs. You start to have elevated insulin levels. So your body is recognizing that my blood sugar is sort of temporary elevated for a variety of factors, whether it's the food, the stress, the inadequate sleep, other hormonal factors. And so we start creating or releasing, driving our pancreas to release more insulin in order to help control those blood glucose levels. And early on, that's exactly what happens. So blood glucose levels are completely normal, but the insulin levels are elevated. Now over time, if this becomes a persistent thing, the body is really ignoring that signal of having increased the insulin such that even an increased level of insulin over time cannot adequately control the glucose. And that's where we start to see glucose levels becoming elevated. And when we talk about elevation of glucose, this can look like a couple of things. If you've ever looked at your annual physical lab work, for example, looked at a basic metabolic panel or a complete metabolic panel, I always recommend to have these labs done fasting. They certainly always don't have to be, but it is valuable at least once per year or more frequently if you're in the active weight loss journey to have a fasting metabolic panel to see what is your fasting glucose level. Now if you look at the range of what's considered normal, this is pretty standard across labs. So there's certain labs where we'll see variation depending on lots of different factors in how the lab is actually developed and processed in that specific laboratory. But the blood glucose level is invariably the same from lab to lab. And what is typically considered the normal range is 60 to 99. Anything greater than 99, so 100 or higher is flagged as abnormal. But what I will argue is that blood glucose levels in the nineties are not normal either, certainly not a fasting blood glucose level. So when you look at your body hasn't eaten for 8, 10, 12 hours perhaps, what is your glucose level doing? Typically your glucose levels should be lower. Your glucose level should be in the order of the seventies, maybe the sixties, maybe the eighties. But your glucose levels at a fasting level should really be in that range. And it's very common that I see people who have a glucose level of say 97 and it's technically normal. So they're reviewing their labs, they're looking for things that are out of the reference range, things that have that exclamation mark next to 'em or they're bolded or highlighted red or whatever to say, look out, something's abnormal here. The glucose level of 97 is not going to flag as abnormal. That's going to just be listed as a normal lab alongside everything else. And what I will say is a glucose level of 97 is not normal. That is actually an abnormal lab elevation and we should not be seeing a glucose level of 97 Now if that is, or fasting glucose level of 97. Now if that is a single thing, so let's say you've repeated that lab a week later or a month later or whatever it was and the level was 70, that's fine. We see fluctuations even depending on what you had eaten the day before, maybe your level of physical activity. So things like going for a run example, your body is, your muscles will turn glycogen, our intermediate energy storage into glucose to help fuel our exercise. So there are other things that can drive up the glucose. So just because that's elevated one time does not mean that it's a problem. But it's very common that I see people who have over the years, their level was in the seventies and now it's in the eighties and now it's in the nineties, and then it's consistently been 95, 97, 96, 98, these upper nineties levels and nobody has said anything to people. So that's an example of a lab that is flagging as normal or not flagging because it's being labeled as normal. But I would actually argue that that is an abnormal level, particularly when we're seeing it year after year. And again, it can be single time elevated for reasons unrelated to metabolic disease, whether it's a meal that you've had the night before, whether it is a dawning effect where your body sort of wakes up. You've got this cortisol spike that naturally happens in the morning to wake us up. We have a glucose response to that, whether it's something like exercise, plenty of things that can elevate that level completely appropriately. But over time, if you're seeing consistently that your fasting glucose level is in the nineties, that is not normal. Now certainly if you're seeing anything in the one hundreds that is flagging is abnormal and that is abnormal, it's very common that I talk to people who've been having some low level elevations that haven't been pointed out to them either. So as we get back to this early compensation and dysregulation, that starts to happen initially we see that the glucose levels are stable and in the normal range, but eventually that elevated level of insulin is not able to adequately control our glucose levels and the glucose levels start going up. So that's what I'm talking about in seeing these levels in the nineties, seeing the levels in the low one hundreds and anything that is in the 100 to 125 range is in the pre-diabetes range. So those low 100 levels, having those consistently two or more readings in that range is consistent with pre-diabetes. We also can look at things like hemoglobin A1C, a normal hemoglobin A1C is 5.6 or lower. When we see things 5.7 to 6.4, that is in the pre-diabetes range. Anything 6.5 or higher is in the diabetes range. Again, this is a test that's very consistent sort of lab to lab, so you're not going to see a lot of variation there. Now I have seen sometimes labs don't flag it until the level is 6.0 or higher. And consistently those elevated five numbers, 5.7, 5.8, 5.9, those are numbers consistent with the pre-diabetes range. And again, this is something that a single snapshot in time may not be as valuable compared to what is happening over the long run. And this is something we see very frequently where someone's level is 5.3, a couple years later, it's 5.4, a couple levels, it's 5.5, no big deal. These are very normal numbers depending on a lot of factors. But then we start seeing the 5.6s, consistently seeing the 5.7s and seeing that over time that number is just ticking up slowly without anyone having mentioned or made recommendations about it. So we'll start to see these low level glucose elevations, and over time those can become more and more profound. Now, when we look at, there are other labs we should be thinking of that can tell us that we're seeing some of this metabolic derangement or other signs, for example, like blood pressure. So it's very common things like our cholesterol. If you look at your traditional lipid panel, there's more in-depth lipid panels as well. But just the very basic lipid panel where you have total cholesterol, you have LDL, you have HDL, you have triglycerides. Looking at those labs can be really telling as well. So we're looking at particularly the triglycerides. Elevations in triglycerides are a sign of metabolic disease. Interestingly, the ratio between our triglycerides and our HDL is important as well. So early on we may be seeing elevations in our triglycerides again as a consistent thing, a single one-time elevation, maybe a reflection of other things like a particularly, let's say you had a fettuccine alfredo the night before, so lots of carbohydrates, some fat with that, the type of meal that can drive up triglycerides in a temporary way. Certainly a single reading is not concerning. But over time, when we're seeing that consistently elevated triglyceride level that gives us, gets us thinking that there may be some metabolic disease. Similarly, our HDL often referred to as our good cholesterol. It's a way more complex story than that. But for the sake of today's podcast, we will continue to refer to HDL as the good cholesterol. Seeing HDL levels come down is also a sign of metabolic disease. And what we can actually do is look at what is the ratio of your triglycerides to your HDL. So if you take your triglycerides on top, divide that by your HDLA ratio greater than three is also a sign of metabolic disease. So we're looking at what is your fasting glucose level? We're looking at the triglyceride number, the HDL number, the ratio of triglycerides to HDL. These can be signs of metabolic disease, of insulin resistance. Now we can also, when we come back to the glucose, start to think about what is actually happening from an insulin standpoint. So there is some data about fasting insulin and more importantly, a lab or calculation rather called the HOMA-IR, H-O-M-A-I-R. And this is really a measure of how efficiently does your body process glucose for whatever level that you have, what is the amount of insulin that's required to do that? So we're looking at our fasting glucose level here. We're also looking at a fasting insulin level here. Now, I have heard people argue that a fasting insulin level is not valuable, but there's actually really good data when you utilize it in the context of this calculation, this HOMA-IR that a insulin level here or that calculation and seeing elevations there in the ratio of glucose to insulin, that that can be concerning for metabolic disease. So this is one of those things too. When we see an elevated HOMA-IR ratio, this can give us an idea that there's this early dysregulation that's happening. We can also, we think about our metabolic panel. So if you're looking at a complete metabolic panel or a hepatic group sometimes called, we are looking at labs that are often labeled things like AST/ALT. Now the ALT in particular is a marker. It's a liver enzyme. It's a marker of your liver health. And this is one of those situations as well where the reference range of the ALT is fairly broad and it's very common that patients have levels that are on the higher end of normal. So they'll have levels, let's say in the low to mid thirties for example, that are not flagging as abnormal. But if you look at they're just one to three points away from the cutoff. The ALT levels are more specific. When you start looking at someone's age and what their liver health should look like, we should be seeing numbers much lower than that. So in the teens, in the twenties, so it's very common that patients have ALT levels that are in the thirties or certainly levels that are even marking as abnormal, marking as low level elevations. And these are not being pointed out. We also will see patients have mild increases in their blood pressure, and this happens at a very gradual fashion as well. So it gets sort of, oh, let's recheck the number, check it a couple times at home, let's check and see what it is next year. But then when you go back and look at a decade of trend, for example, what we see is that a decade ago, someone's blood pressure was consistently in the normal range and now they've started having these low level elevations, the upper one twenties over eighties, one 30 over 90, starting to see these elevations that are pretty consistently there. And we might be able to check the blood pressure multiple times and say, oh no, we can bring it back down to normal. Maybe you have white coat hypertension, if you've heard that phrase of I go to the doctor and my blood pressure is elevated. Now that is certainly a real disease. It's certainly true that there are people who check their blood pressure consistently at home and always have normal levels, and then they come into the doctor's office and it's elevated. I'm not saying that doesn't exist, but it's very common that people are starting to see these low level elevations. They're not checking their numbers at home and we say, oh, let's just keep an eye on this. And then over time, we've seen all these things adding up. So people may be seeing a single irregularity, but what ends up being really common, and what I see in my practices a lot is that people have these glucose abnormalities. They have levels in the nineties and the low one hundreds, they have elevated liver enzymes, particularly that ALT. They have elevated triglycerides, a low HGL. They're starting to see increases in blood pressure. And alongside all of this, they've been super frustrated because they often have physical symptoms and signs that their body is not utilizing energy efficiently. They're starting to notice that they're gaining weight. So that very classic story of, oh my gosh, I feel like I have been doing everything right and I'm not seeing weight loss. That is a very classic story sometimes for menopause, but certainly for metabolic disease, we are all of a sudden my body is just not working in the way that it was. And so I'm starting to notice I can't lose weight or maybe I'm starting to gain weight despite things feeling the same. I'm noticing particularly weight around my midsection. So noticing that weight is coming on in the middle of my body. Sometimes it's things like recognizing our energy level throughout the day, feeling like we get really fatigued after meals or even this sort of crashing sensation after meals, having a lot of hunger or particularly cravings. So finding that we're having cravings for sugar, having cravings for carbohydrate. Sometimes there's other changes. So we're seeing for women irregularities in their menstrual cycle. Sometimes this can be a sign of PCOS, polycystic ovarian syndrome. There are skin changes that can happen. So even skin tags, for example, can be linked to metabolic disease. Now, skin tags are not always a sign of metabolic disease. They can happen for other reasons, but skin tags are a sign or can be a sign of metabolic disease. So if you're noticing skin tags that are developing where you hadn't been dealing with them before, there's a condition called acanthosis nigra cans, which is basically a browning of the skin. So very commonly like around the neck, for example, sometimes around the broad line underneath the arm, people will notice there's this, people describe it as like a velvety appearance, but the skin gets this sort of browning to it in patches, sort of broad patches that can be a sign of metabolic disease. So it's very common that patients go and have the story of they're not feeling well, they're feeling tired, they're having cravings for food, they've been gaining weight centrally, or they're not been able to lose weight, maybe starting to notice skin changes. And all of these things are signs that that metabolic disease is accumulating and needs to be addressed. Unfortunately, it doesn't always get addressed until we've noticed those overt lab changes. So noticing pre-diabetes where that A1C has elevated noticing full-blown diabetes, maybe noticing other things with cholesterol or with blood pressure, and we're treating the individual conditions. But the reality is we need to be thinking about that underlying disease process and how do we support that. Now, one of the reasons I'm so passionate about this is supporting someone earlier in their metabolic derangement is so much easier to reverse compared to when our body has compensated and become dysregulated over time. So if you look back, and I'll encourage you even pause this episode and go look at your labs from last year or after this podcast episode is over, go to your online profile and pull up, okay, what were my last, what was my fasting blood sugar? What was my ALT, that liver enzyme? What did my cholesterol number look like? And if you're seeing elevations on any number of those things, that is a sign that you've got some metabolic disease going on, and let's work on reversing that now. So we think about reversing metabolic disease. That can look like a lot of different things. There's certainly may be medications that we're considering, but ideally we can do this even very early on with lifestyle interventions. So we want to be thinking about regular movement. This can look like walking, for example, working on strength training. That resistance training to build up our muscle, both regularly exercising and then particularly prioritizing muscle can be really helpful for reducing insulin resistance, improving our insulin sensitivity, our body's utilization of blood sugar. We want to prioritize protein in our diet, prioritize fiber in our diet. These are things that both create initial satiety as well as lasting satiety. Help us to have even levels of energy. Last week we talked about the role of no naked carbohydrates and no naked carbohydrates is the perfect thing to implement honestly for anybody. But particularly if you have early signs of metabolic disease, think about how do I get in protein? How do I get in fiber? If I'm going to have a carbohydrate, how can I partner that with a protein partner that with a fat, make sure that I'm creating a more well-balanced meal? This can go a long way in improving our body's insulin sensitivity can be really, really valuable. Now, if it's been a while since you've had labs or you're wondering what do things look like right now? Or maybe you've had an incomplete panel, a lot of times those routine labs are valuable. So you go to your doctor, you get a blood count, you get a CMP, the complete metabolic panel. You want to make sure it is a complete metabolic panel. A basic metabolic panel does not have that liver portion. Sometimes they're separated out, so it'll say basic metabolic panel and hepatic panel or hepatic group or something like that. But a complete metabolic panel, you want to make sure that has those liver enzymes. So you're looking at an ALT. Again, that's not a specialized lab. It's something you should routinely be getting a hemoglobin A1C. I would ask for that even if you haven't had signs of full-blown diabetes. Checking from a pre-diabetes standpoint can be really valuable. A traditional lipid panel can be great. I check a fasting insulin level very frequently, particularly because I'm doing this HOMA-IR calculation where you're looking at that glucose and insulin ratio looking at measurements like not just weight, but our waist circumference. So we can look at things like just our waist circumference by itself. We can look at our waist to height ratio. This has recently been called the BRI, the Body Roundness index. But basically saying for your waist to your height ratio, is there a concern that your waist is growing disproportionately? And so if you're noticing that you are gaining weight, particularly around the midsection, this is a sign of metabolic disease. So certainly that's something you can track on your own or you can do that in combination with a physician. And then there's medications we can consider as well. This may look like medications like metformin, which is a pill commonly used for the treatment of type two diabetes. But this works on underlying insulin resistance. Great nudge in the direction of someone's goals. I have a lot of patients who do have early metabolic disease for whom starting metformin can be a phenomenal medication and really help them. I have patients who describe it like the way we describe GLP in terms of they're like, oh my gosh, I have so much appetite suppression. My energy levels feel really stable. I'm not as hungry as often. So that can be a really phenomenal medication, whether the Effexor it are that overt or not, or even medications like the GLP or GLP/GIP medications. So things like Ozempic, Wegovy, Zepbound, Mounjaro. These medications can be really effective for metabolic disease and may or may not make sense depending on the rest of your health picture and the severity and all of that. So it does make sense to have a conversation one-on-one with your physician. Absolutely. I always recommend that you should schedule an appointment. Do not send your doctor a message on MyChart and say, Hey, I heard this podcast. Please reach out. Schedule an appointment. Have these labs done. Give yourself and give your physician the time to dedicate to a conversation around this. And if you're finding that you're not getting the answers that you want, I would encourage you to ask them, okay, who can I see? Is there an obesity medicine physician you recommend? Is there someone else who can give me advice on this topic? If you are in Illinois, Virginia, or Tennessee, I would love to see you as a patient. In my practice, I see patients throughout those states by telemedicine as well as in person in Charlottesville, Virginia. And I find so much passion in helping to support patients anywhere in their metabolic journey. But it's amazing even early on before someone's dealing with clinically significant obesity, how do we support someone in reversing these early things? And it makes such a difference in the trajectory of the rest of your life. So if you have questions, I would love to support you with that. You can learn more about me at www.sarahstambaughmd.com. We'll have that link in the show notes. Thank you so much for joining me for today's episode. We'll see you all next time. Bye-bye.