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 in your weight loss journey for a while now, you are likely experiencing some slowing down on the scale and it can be actually pretty panic inducing. Oh my gosh, I still have a while to go. Perhaps I still have more weight loss goals, and yet I feel like that number is really slowing down. This is a lot of times when patients come to me, we’re having a patient visit and it’s like, oh my gosh, I just feel like I’ve been at the same number week over week, month over month. And they’re kind of panicking because they’re like, I’m not done with my weight loss journey. I know that I have more to lose. And yikes, is the end in sight. And so today we’re going to talk about that because my guest, if you’ve been on your weight loss journey for any period of time, this may be coming up for you as well.

And if it hasn’t, it likely will at some point in your weight loss journey. So definitely take a listen now so you can be prepared and save this episode, subscribe to my channel on YouTube if you’re not following me over there so that you can come back and revisit this topic because this is where things get really, really stressful. Things are going well. Maybe you’re on a medication, you feel like you’re in a good routine, the numbers are slowing down and now your head starts setting in with panic of, oh my gosh, everything’s going wrong. So let’s dive into this and what is happening both physiologically? When do we know if it’s a problem? And then what are you going to do about it? So let’s talk about weight loss. I think one of the things that’s really exciting when I’m working with people in the first one to three months of their journey, a lot of times the scale plummets.

Now, when I say that, I’m especially talking about people who are using medications like the GLPs, like Zepbound, like Wegovy, to help support in their weight loss journey. And it can be really exciting because a lot of times people have felt stuck for a long time. They’ve been excited to get going in a program. They get started on their GLP and their weight feels like it falls off almost literally overnight in some cases. And what’s very common is that first month in the weight loss journey, sometimes we see really, really significant weight loss. Now, this isn’t always the case. And if you’re listening and you’re like, “That wasn’t the case for me. I lost three pounds in my first month.” Nothing goes wrong with that either. Everybody’s body is unique depending on where you’re starting, what your previous journeys have looked like. But what is a common story is that people will lose weight more significantly in those first couple of months and we’ll see 10 or 15 pound weight loss sometimes.
And it could be really exciting to see the scale drop down that quickly. Now that’s something we’re working through too, is what is your relationship with the scale and do we get excited versus discouraged when we see a number on the scale? But people feel like, “Hey, this is working.” They get really excited about that. So that early weight loss, a lot of times we see really rapid fluid shifts that happen. We see this for a handful of different reasons, but a lot of it is our body working through different energy needs. We have short-term energy storage in the form of glucose that’s our active energy in the bloodstream. We have intermediate energy in the form of glycogen. Glycoten is stored in our liver, stored in our muscles as a intermediate form of like, “Hey, you’re going for a run, for example, and you use up any active glucose that you have and your body dips into its glycogen stores to help continue fueling your body.” So a lot of times we’re dipping into glycogen and then fat stores being our sort of reserve energy that is available for us.

And a lot of times I’ve heard it referred to with the analogy of how we get food, for example. So glucose being, you go to a restaurant or get takeout and you have food totally ready and prepared in front of you. Glycogen being ingredients that you have in your refrigerator. So you could pretty quickly assemble those into food so you could rapidly turn it into food, but it’s going to take a little bit to convert it. If you’re going for the easiest option, you’re going to go for glucose before dipping into anything in the refrigerator. And then fat stores being our deep freezer. So you can absolutely access those, but most people aren’t going into their deep freezer unless it’s for a very specific reason. You open the refrigerator, the glycogen stores, and you’re like, “Oh, it’s kind of empty. I should probably see what I have in my freezer.” And then you go and you find, okay, here’s some meat or here’s a meal that I made previously and I’d like to eat this, but you know that you have to sit it out and defrost it and that’s going to take a while.

And so while we can absolutely use our deep freezer, it’s not going to be our first option, especially when we need energy stores right away. So we’ve got this glucose, we’ve got glycogen, we’ve got fat stores. What’s really interesting about glycogen specifically is the glycogen that’s held in our muscles also holds onto water with it. And so as our body is rapidly depleting excess glycogen stores at the beginning of our weight wash journey, we often have a major diuretic effect that comes with it and our body is urinating more frequently. And so now our body’s still always rebuilding and has some glycogen stores, but a lot of people will find that this really significant urination happens at the beginning. This also can happen in ketosis. So people who are on a ketogenic diet as we lose fat and as our body is breaking down fat, one of the things that’s really interesting, I think we think about fat just being like, poof, it disappears off our body.

But the reality is we break it down and that our body has to do something with those byproducts. So fat is broken down into carbon dioxide and water. So the carbon dioxide, we predominantly exhale, so we breathe out and the water we predominantly urinate out, although we can sweat it out as well. But people will notice that they’re urinating a little bit more frequently, especially at the beginning, and this creates a really significant movement on the scale, and so that’s one of the big things that we’re seeing early on. Now we also, if you’re starting a GLP medication, one of the things we know is that appetite suppression is most significant initially on these medications. There’s a delayed gastric emptying effect that comes up with any of these GLP medications. And when that effect has been studied, it’s been most significant in the first month or so after starting the medication or after increasing the dose of medication.

So a lot of people, when they first start the medication, notice some of this. They feel nausea, maybe they feel like reflux and having acid or even food come back up. There might be burping or belching. They might feel full or uncomfortably full after eating. They might notice their very small amount of food creates the feeling of fullness. And so they have a dinner prepared in front of them. They feel appropriately hungry. They go to eat their dinner and they have four bites of their dinner and it’s like, “Oh, I’m pretty full already.” Now, I will give the advice, especially at the beginning of your journey, if you feel full, stop your meal, or actually at any point in your journey. If you feel full, stop your meal. But I think the thing that’s hard at the beginning of your journey is that feeling of fullness comes up really quickly sometimes.

So that feeling of fullness is surprising because you’re like, “How did four bites of food create this feeling of fullness for me? ” And so that is the delayed gastric emptying effect that will diminish over time. And sometimes this even in and of itself can be a little bit panic inducing because people will notice that they have more appetite or when they do eat, they can eat more, but that’s not necessarily a problem. It’s just sort of your body settling into the medication. But if you do have that delayed gastric emptying effect, it’s early in your journey, you’re listening to that and not overeating. If you’re listening to the audio version, major air quotes there, because again, it might not be a huge amount of food that creates that feeling of, “Ugh, I ate too much,” but all of this can drive also a pretty rapid decrease in weight because you’re not fueling your body as significantly.

And again, that’s not even necessarily a problem in that when we think of energy needs, food at its core is just fuel. So food is fuel for our body, but that’s actually also the entire reason that we have fat stores on our body. Our body stores fat for times where food is not readily available. And so in the beginning of your journey, when you’re eating a little bit less because of that delayed gastric emptying effect, your body may be dipping into fat stores for energy because it’s simply not getting as much fuel in the form of food entering into your mouth. And that’s okay. We want to make sure that we’re paying attention and that adjust over time, but that’s okay. Your body has stored this fat for a reason, and so it’s excellent that we get the opportunity to dip into it. Now, today’s episode is not going to be terribly much on muscle preservation, but we do have very specific energy needs for specific things.

So if our body is dipping into fat stores, that’s great and find and dandy, but we do also know that muscle mass loss can come in the weight loss journey and we want to make sure that we are adequately supporting our body with protein so that we’re not going to preferentially lose muscle mass and that can have downstream effects of metabolic adaptation. We’ll talk about that here in just a moment, but making sure that even if you’re not eating as much that you are emphasizing protein a lot of times with that delayed gastric emptying effect, it might mean things like protein shakes, protein waters, yogurt, eggs, sort of easy to digest type of things because you may not feel like having a large volume of food sitting in your stomach. But all that to say, we see weight loss more significantly at the beginning. And the slowing down is not only normal.

I will actually argue, and I argue this almost every single day, it is a good thing. You do not want to, let’s say you lose 20 pounds the first month or something. You do not actually want to live in a body that has lost 20 pounds per month, month over month for a year. Even if you had that amount of weight to lose, that is a very rapid and significant amount of weight. That was probably an extreme example. And you’re probably listening thinking, Dr. Stombaugh, of course I don’t want to lose that much, but even 10 pounds, 10 pounds per month, month over month over the course of a year, that’s 120 pounds. And if your body lost that weight that rapidly, you would likely feel that effect really significantly in your body in a way that you hear people talk about like Ozempic face or Ozempic butt.

And the reality is rapid weight loss can drive some of these effects. It can also drive things like hair loss, for example, because your body can be feeling like it’s malnourished and feel like, “Oh my gosh, there’s no food, there’s no nutrients available to me. ” And so that can be a driver of telogenefluvime where we have significant hair loss. Other things can drive that as well. So if you’re having significant hair loss, it does not mean that you’ve had malnutrition by any means. We do know that just losing weight can be a trigger for that. We’ll absolutely talk about that in other episodes as well, but make sure that rapid weight loss is not actually good. The goal is not to just not eat anything for a period of time. The goal is to feel like you’re supported in fueling your body in a way that feels good, in a way that feels energizing, in a way that feels like your body is really well fueled and you can get through your day-to-day activities and really thrive while doing those.

Because here’s, I’ve been kind of alluding to the problem with metabolic adaptation. When we lose weight incredibly rapidly, when we are not protecting certain parts of our body like our muscle, we are at increased risk for seeing problems with metabolic adaptation. Now, some metabolic adaptation effect is normal and expected during the weight loss journey. When we lose weight, we are going to lose a combination of fat mass and muscle mass. It is almost impossible to exclusively lose fat mass. Our body is going to lose some muscle mass, and I will tell you that that’s okay. You can imagine, for example, if you put on a 40 pound weighted vest right now and you walked around and every single activity that you did, you walk into the mailbox, going on your exercise, every single household chore that you do, you had a, let’s say, 40 pound weighted vest on your body.
You would gain muscle mass just from carrying around that 40 pounds of extra weight in the form of that weighted vest. Now, if you took that vest off your body and you set it down, you would lose some muscle. If you weren’t doing anything differently, your body would lose some muscle because it’s no longer having to carry around those 40 pounds. Now the exact same thing is true with our bodies, that when we have whatever body weight we live in, let’s say we lose 20 pounds, 50 pounds, a hundred pounds, your body now, every single thing that it does, your legs, your core, your abdomen, your back, you no longer have to carry around and support that amount of body weight. So there is some decrease in muscle mass that is common, that is appropriate, and there’s nothing wrong with that. What we want to prevent though is a disproportional increase in muscle mass.
Now, one thing I will say, and I’m very sensitive to, is that I think there’s been a lot of fearmongering in this place, a lot of fear mongering of like, “Oh my gosh, you’re going to lose all your muscle mass.” And I’m almost even cringing, as I said before, about Ozempic butt and Ozempic face. I do not want you to be worried about those things.
If we’ve had excess weight, there may be loose skin and there are solutions for that as well, and we can work through that if that comes up. But what we want to make sure that we’re doing is as you’re losing weight, that you’re able to fuel your body, that you’re able to think about your protein needs, that you’re able to think about your micronutrient needs, so your vitamins, your minimals, and that you’re able to address those because we do see that there’s a slowing down of effect over time, and some of this can be from metabolic adaptation. Now, part of this is if your body’s been in a caloric deficit, our bodies get really efficient with energy use. And this is actually a great thing. In terms of survival, if you had no access to food for a period of time, you would want your body to be incredibly metabolically efficient, meaning that your body does not need as many calories to run its day-to-day activities.

This would be a really good thing. The problem is in this era where we have abundant access to food, it doesn’t serve us. We’re trying to lose weight, we’re desiring to lose weight, and our body’s like, “Oh gosh, I might be starving here. Maybe there’s a falmin going on. Let me conserve energy.” So we do see that that can happen during the weight loss journey where we have this decrease in metabolic effect. You also are living now in a smaller body, and it simply also takes a less amount of food to fuel a smaller body compared to before your weight wash journey. So there’s lots of different effects at play. Now, preserving muscle is one of the best things that we can do to make sure that we’re not disproportionately losing muscle mass, that we’re preserving our metabolic rate as much as possible. This means eating protein, this means exercising, particularly with resistance training.

That can make a really big difference too in the weight loss journey. Now what’s interesting though is that the volume of muscle mass and the volume of fat mass are very different. If we think of five pounds of muscle, it’s like this little brick where five pounds of fat is like this big globular thing. Now those weigh the same, but if we think about the way they feel and fit on our body, they’re very different. So one of the things also that messes with our head a little bit, but we’ll see sometimes that the scale is not moving in the way that we expect it to, and it can feel really frustrating. Yet, if you pause and look at non-scale victories, you’ll see things like, “Oh my gosh, my pants size is smaller. My bra size is smaller. If you’re measuring your waist circumference, that feels different.
Maybe you notice how active you are and what you’re able to do in the gym, the amount of reps you can do, the amount of weight you can lift, for example, and it can be really empowering to see some of those changes, but we do often see a slowing on the scale because that muscle is very dense. And so slowing on the scale in that case is not even a bad thing at all. In fact, it’s a really good thing. Now, what I want you to think about is, okay, what is slowing on the scale a problem? And okay, what should I do about that? ” So slowing on the scale can happen for a lot of different reasons, and this is often a really good time for us to reevaluate, okay, what’s happening? For one, is there actually a slowing in a scale? What I think is really fascinating, a lot of times our minds lie to us like nothing’s happening here, but if you step back and look even over the course of a month, there may very well be changes that you’re not aware of.
And you might be listening to this and say, “No, Dr. Stombaugh, I know that there aren’t, but I promise you, if you look over the last month, there are wins that you have had.” And if you feel like everything has been a failure or has been a setback, we can also use that as a learning opportunity for how do we fail forward? How do we learn from that in a way that helps you to succeed next time around? But what’s really powerful to me, and I see this every single day in my practice, is that patients will say like, “Man, I don’t feel like I’ve really lost anything over the last month.” They’ll say, “My weight’s the same.” I’m like, “Well, what is your weight? What is the number that you’re seeing on the scale at home?” And then we actually look at the numbers and it’s very commonly down three, four, five pounds and like, “Oh, I didn’t realize it was actually that much higher at our last visit even just one month ago.” So really not just assuming what the trends are, but really taking a look at the data.

One of the challenges too is that when we weigh ourselves, especially daily, which I think can have certain benefits, and we’ll talk about that in other conversations, but we see the number is up and down and up and down, excuse me, and it feels like nothing is happening. But then if you take a step back and look, there’s actually this slow, downward slope that is happening and it’s slow, which is fine, which is good even. And there’s absolutely a downward slope that’s happening there. It’s just not obvious always with this day-to-day up and down that is happening. And so sometimes having a third party, having someone like myself, another obesity medicine physician who can review that with you and either A, say, actually things are going pretty well here or B, okay, I agree with you. I’m seeing the problem that you’re seeing. What are the changes that we can make?

And we can reevaluate what is happening day-to-day nutrition-wise, what is happening day-to-day exercise wise? Are there sleep? Are there stressors? How are we supporting you from a medication standpoint? Is it time to increase your dose of medication? Is it time to switch your GLP? We’re going to have an entire conversation about that next week of should you switch your GLP medications because GLPs are not all created equal. And we’ll talk about whether it’s from a effectiveness standpoint, whether it’s from a side effect standpoint, should we be switching your medication? That is absolutely a conversation that will make sense to have. And so this might be a point where we’re thinking about it. If we’re truly seeing, okay, weight loss is not just slowed, but it’s actually stopped. If there’s other problems that are coming up, we might be thinking, are there other medical conditions going on?

A lot of times at the beginning of the weight loss journey, we’re screening for things like thyroid disease, for example, but things can crop up. When was the last time you had your thyroid checked? Is there conditions like Cushing’s disease, for example, that are going on? Are there genetic causes of obesity that we haven’t yet screened for? Is there anything happening hormonally? Either just month to month, menstruation can cause bloating and weight retention over a period of sometimes like a week, or are there things like perimenopause or menopausal changes that we also need to be supporting? So we get this chance to step back and see, okay, how do we re-optimize and rego from here? So I want you to know that there is hope. If the weight loss feels like it is slowing down, there is absolutely nothing wrong with that. In fact, it may actually be a really good thing, but if it is slowing, if it is plateauing, there are steps that we can take from moving forward to continue to support you in your weight loss and in your health goals.

I would love to be the person to help you with that. If you are in Illinois, Tennessee or Virginia where I see patients by telemedicine, my physical clinic is in Charlottesville, Virginia, and I would love to see you in person if you were nearby to me. If you are not in any of those places though and you’re like, “Oh my gosh, Dr. Stombaugh, I wish I could get support from someone like you. ” We have a great online program called The GLP Guide, and it is a great tool for frequently asked questions and answers to all those questions you have. You will get videos that are organized to address certain side effects. When should you adjust your medication? How do you travel with your medication? How do you use your medication? Maybe you’re switching to a new form of medication and feeling intimidated by that.
We have so many videos to address the questions that you have. And I think the best part is that my goal is for that to be a growing and evolving resource. So if you review it and you’re like, “Oh shoot, Dr. Stombaugh, you told me there’d be a video on this topic and I don’t see that, ” reach out to us and we will add that to the video guide, not only for you, but for anyone who has that guide. So I want to be able to support you the best I can in your weight wash journey. Thank you so much for joining me for today’s episode. We’ll see you all next time.