243. Weight Loss Medications With Paul Kolodzik, MD (Correct & Incorrect Use Explained!)

Morgan Nolte, PT, DPT (00:06.542)
Hey there and welcome back to the Reshape Your Health podcast. I'm your host, Dr. Morgan Nolte, and I cannot tell you how thrilled I am to have this conversation today. I think it's gonna be one of the more popular episodes that I've ever done because it's on a hot topic of weight loss medications. My guest today is Dr. Paul Koloszczyk, and he is a board certified physician both by the American Board of Preventative Medicine and the American Board of Emergency Physicians.

In a 30 year emergency room career, he has witnessed firsthand the failures of mainstream diets and the medical system overall, which prioritizes medications and surgery over diet and lifestyle changes to prevent and reverse disease. And if you've listened to me for any length of time, you know that that is right up my alley. and I was so excited to hear someone equally passionate about disease prevention and in his metabolic practice, Dr. Klossik,

uses the technology of continuous glucose monitoring to help his patients achieve weight loss and improved health. He also has integrated the prudent use of new weight loss medications into his practice. And that is what we're talking about today. Semiglutide, Wegovy, we're going to talk about all of the most asked questions that I've been seeing online. In his recently published book, The Continuous Glucose Monitoring Revolution, Dr. Klossik,

presents a comprehensive program for metabolic health success using CGMs and limited use of weight loss medications. I already know our philosophies are going to be so well aligned. Dr. Paul, thank you for coming on this show. Yes, well, let's get started just with, you know, semaglutide is the, you said generic form, right, of the medication. How does it even work? Let's start there.

Paul Kolodzik (01:46.546)
Thank you for having me, Morgan.

Paul Kolodzik (01:59.762)
Okay, so just to get kinda the name straight, semaglutide is the generic term for Ozembic and Wigovie. They're all the exact same medicines. And then on the other side made by Lilly is Monjuro, which people have heard of, which is the exact same medicine as Zepam, which is the weight loss branding, but they're the exact same medicine and the generic for that is Terzipatide, just so people...

kind of know the terms of this. So these medications, as you probably know, were originally used for diabetics because they had a special quality where they control blood sugar, but they don't cause hypoglycemia. So the pharmaceutical firm, Novo Nordis, initially realized that the diabetics on this medication were losing weight.

And so they thought, well, it doesn't cause hypoglycemia. Let's go back and do some studies on patients that are not diabetic but are overweight. And the same thing happened. Patients lost between 14 % and 17 % of their body weight during those studies. So then they went ahead and got them approved as FDA medication. So that's kind of the history of these medications. You asked how they work. They basically have three mechanisms of action.

The first is that they slow gastric emptying. That's a fancy way of saying your stomach stays fuller longer. There's a valve between the stomach and the intestines called the pyloric valve and it narrows that valve so your stomach's gonna stay fuller longer. The second mechanism of action is that it lowers blood sugar just like we talked about. And you know, this is kind of what my practice has been built on to some degree for the last seven years. If you lower blood sugar,

You know, blood sugars are high in America in general because of excessive carbohydrate intake, the issue of insulin resistance. So the focus of low -carbon intermittent fasting historically is to lower blood sugar. And then the organs in your body, let's say your muscles start looking around for another source of energy. And that other source of energy is often the fat that is deposited around our middles. And so that's the other, the second mechanism of action of these medicines. They lower blood sugar. So you,

Paul Kolodzik (04:20.05)
essentially burn more fat. Does the same thing to some degree as a low -carb approach in intermittent fasting. And then the third is they have a direct effect in the brain in the hunger center, the hypothalamus of the brain to suppress hunger. And so those are the three ways these medications work. And as you're aware, they've been fairly effective at helping people lose weight with those three mechanisms.

Morgan Nolte, PT, DPT (04:49.262)
And specifically with the effect on the brain is that they're a GLP -1 agonist.

Paul Kolodzik (04:55.25)
Yeah, so basically they are, that's a great point, I didn't bring it up. So GLP stands for glucagon -like peptide. So these substances are mimicking a natural hormone that, for example, helps suppress hunger. So it's basically an analog or a mimic of natural hormones in the body. So they kind of take over and accelerate the effect of the natural hormones.

Morgan Nolte, PT, DPT (05:23.63)
what things, I know that like protein, maybe fiber, maybe water can stimulate GLP -1 like these medications do, but what natural things aside from these medications can help stimulate that GLP?

Paul Kolodzik (05:37.458)
Yeah, you know what one of the main ones one is and you know, being an advocate of low carb diets, you know, low carb diets have a tendency to be higher fat diets. So, you know, you focus on low carb, generally higher protein, but low carb diets are generally higher in fat. And one of the biggest GLP one stimulants is fat. And so when I have my patients, I'm not insensitive to cholesterol issues.

But when I have my patients want to work on suppressing hunger, we go low carb and higher fat. Think about it. You can only eat so much steak, but you can eat bag of chip after bag of chips. So I think fat is an important component of a low carb diet. And fat is one of the macronutrients that stimulates GLP -1 hormones.

Morgan Nolte, PT, DPT (06:28.91)
Okay, awesome. I just wanted to point that out that you can get a similar satiety effect by kind of changing your macronutrients up a little bit. I'm gonna ask the elephant in the room question, and this was one that I asked you offline. Is this okay for me to ask? I want you to explain the profit motive behind these weight loss medications and how people can differentiate.

Paul Kolodzik (06:38.354)
Absolutely.

Morgan Nolte, PT, DPT (06:54.958)
if this is a profit -driven business trying to sell you a medication to make a lot of money versus if this is an ethical practice that is using medication wisely as part of a more comprehensive plan of care.

Paul Kolodzik (07:11.506)
Yeah, so I would ask right from the beginning, and I stole this term from Stephen Covey, The Seven Habits of Highly Effective People, is begin with the end in mind. So begin with the end in mind. What's the end in mind? Because I don't think many people want to start a medication, and the end is that I'm just going to be on this medication for the rest of my life and be dependent on this medication for the rest of my life. So if you're looking at providers or interviewing providers that are looking at

prescribing this medication, then you gotta get a sense of what is the end game here. And in my mind, the end game should be medication use usually less than a year, measured in a period of months. Because a more profit -driven approach would be, we wanna get you on this medicine and keep you on this medicine for the rest of your life, because then you're gonna be a customer for life. So I think people that are looking at different...

options for these medications need to begin with the end in mind. And then that usually drills down to, you know, what sense do you have that the provider wants to eventually get you off the medicine? And that is reflected in what are the support services that you're going to be provided? Is there going to be nutritional counseling? Is there going to be a structure and support for whatever your workout regimen is? And...

You know, as you and I talked, I've been doing this well before these medications came out in terms of focusing on reversing insulin resistance, which is, you know, the primary approach to helping people, middle -aged, overweight Americans lose weight. And so, you know, I believe that program necessarily includes a low -carb approach, intermittent fasting, and strength training, because strength training also decreases insulin resistance. And coincidentally,

you lose muscle mass on these medications. So strength training is a critical aspect of that. So, you know, try and get a sense of what the end game is and then get a good sense of what your support services are.

Morgan Nolte, PT, DPT (09:16.942)
And so you said that compounded medications are different than the brand name medications on like the profit margin for physicians. Will you just kind of explain that a little bit too?

Paul Kolodzik (09:28.434)
Yeah, so when docs write a prescription, generally there's no kind of kickback, at least not that I'm aware of. So that's a good thing that I'm not aware of that. So if you get a prescription for Azembic or Wigovia or whatever, obviously there's other entities that have stakes in that game, the pharmaceutical distributors and the pharmaceutical company.

Morgan Nolte, PT, DPT (09:39.15)
Yeah.

Paul Kolodzik (09:52.626)
If it's a compounded medicine, and compounded medicine, it's not exactly a generic, but you can think of it as a generic. Compounded medicines are the alternative non -brand name medicines. And they can be provided through providers, and I in fact do that myself, provide it to patients, and they're generally at a lower cost. This is allowed at this time because there's a shortage of, for example, Wigovian ZetBound. I don't know if it's gonna continue indefinitely.

But providers that supply these medications will have some kind of margin built into that. I would like to see a majority of that margin going to these support services that we talked about and not just a pure profit motive. And I'm trying to draw a contrast again between a private practice like mine and just getting on the internet and getting somebody to send you medicine.

without any support and maybe even hopeful that you're going to be a lifetime client of theirs.

Morgan Nolte, PT, DPT (10:55.438)
Yes, before this interview, I was Googling something about some aglutide and it essentially popped up all of these sponsored ads on like just $99 a month or $139 a month. And it's like those types of ads probably indicate that this is somebody who just wants to prescribe you the medication and not necessarily provide the support services necessary to help you successfully like wean off of the medication.

And there's so many questions that I want to ask and I definitely will. We did a good job preparing for this episode, but let's kind of talk about the next logical question, which what are the out of pocket expenses that you're seeing for your patients right now? And, you know, is this covered by insurance at this point in time?

Paul Kolodzik (11:39.314)
Right. So, yeah, we, you know, the cost issue is a big issue here. Right now, from what I see, maybe 10 to 15 % of insurances are covering this medication. Now, I need to clarify, if you're diabetic, Ozembic or Monjuro is applicable. Again, same medicine. And that can be readily prescribed to diabetics and...

for most people on insurance. However, if we're talking about only a weight loss focus, Wigobi and ZepBound, the coverage is limited. And then full out of pocket cost, if you don't have it on your company's formulary, so to speak, is about $1 ,000 a month. So that's really not affordable for people. And so there is an alternative, which is the compounded medicine. There is generally about a third.

that cost and from my perspective, equally effective. But insurance coverage is a big issue and even the compounded medication cost is prohibitive for some people. It's another reason I should mention sometimes the cost is dose dependent. It's another reason that we'll talk about trying to keep the doses low.

Morgan Nolte, PT, DPT (12:46.35)
Yeah.

Morgan Nolte, PT, DPT (12:54.286)
Yeah, you were talking earlier about when we were offline, the sustainability and like whose responsibility is this and how some insurance companies are starting to cover it. Some are like stopping. So can you kind of walk us through just the complicated atmosphere right now of coverage? Because so many people, if they start covering it for weight loss,

Paul Kolodzik (13:08.722)
Yeah.

Paul Kolodzik (13:14.002)
roommate.

Morgan Nolte, PT, DPT (13:19.182)
would qualify because over seven out of every 10 adults in America are overweight or obese. And so who's bearing these costs?

Paul Kolodzik (13:28.402)
So that's a great question. So the reason that insurance is slow to cover some of these medications is just, you know, it's an economic issue. There are companies that covered it early on that realized it was a break in the bank in terms of their healthcare costs and they couldn't do it. Not many Medicaid, state Medicaid programs have covered it, but I heard North Carolina covered it and they had to stop covering it.

it because of the cost. There are some large employee systems that again have reversed coverage and it's because you know a thousand dollars a month for 60 or 70 percent of your workforce is not sustainable. And then the whole issue of associated accountability comes up in that. Who's going to pay for that?

If somebody's paying, if insurance is covering that, do you have any responsibility in terms of doing the other things that you should be doing so you don't become dependent upon the medication lifelong? So things are going both ways. Some companies are dipping their toe into the water of providing coverage, sometimes requiring a comprehensive program if somebody's gonna be on the medication and other companies have backed off providing coverage. Interesting Medicare.

covers people over 65 years of age, has actually, historically, this is interesting, been prohibited by Congress from covering obesity medications. So that's why, for example, Zetbound and Wigobi now are not covered by Medicare. So if you're over 65, that's unavailable to you. Now there's been a little chink in that armor in the last couple months where...

The drug companies are doing more studies to finding more applicability for the drugs. And one thing they found was that for people that already have documented heart disease, it can reduce the risk of progression of heart disease. So Medicare did say, well, if you are overweight and you have heart disease, we'll look at covering that. But the indications and the coverage is just moving back and forth.

Morgan Nolte, PT, DPT (15:37.998)
That's so interesting. And you're right. Like the Medicare in and of itself is not sustainable. I mean, I'm a physical therapist. And when I was practicing regular, that conversation was coming up all the time about Medicare slashing coverage for PTs and PTAs and reduced visits and all that stuff. And I'm really, really glad to be outside of the insurance system so that I can just provide the care that I believe that people need. So that's really interesting. Thank you for bringing up those points. Now you've mentioned the importance of low dose.

Paul Kolodzik (16:00.914)
Yes.

Morgan Nolte, PT, DPT (16:07.534)
several times. And I would love for you to describe what is technically in your mind a low dose of semaglutide or a comparable medication compared to a high dose so that if somebody is looking to take this medication or they're on this medication, they can check their prescription and say, well, I'm on a high dose. Should I switch to a low dose? And if so, what should I ask for there?

Paul Kolodzik (16:35.09)
So let's talk about the way these medications are prescribed so I can answer that question. So as you probably know, you started a low dose and the dose is titrated up over a period of months. So it's moved up. And the reason for that is because of the side effect profile. These medications routinely cause nausea. I would say in the majority of patients, there is some risk of nausea. There is, of course, a laundry list of other potential side effects and complications.

I think if you use the medications prudently, which is in low doses, you don't see a lot of that, and I haven't seen a lot of that, but nausea is common. But you gotta titrate it up, and let's talk about semaglutide numbers to begin with. You start at .25, this is Ozempic and Wegovy same thing, you start at .25 milligrams a month, and you take, excuse me, a week, and you take it weekly for a month. And then after...

your body accommodates to that. Usually by the third or fourth dose, you aren't getting any nausea anymore and you pop it up and that pattern may recur and you get more nausea. So when I use these medications, I usually go through that progression up to a ceiling dose of about 1 .5 milligrams. So pretty much everybody starts at 0 .25, go to 0 .5, go to one, go to 1 .5. Now, Wigovie can go up to 2 .4 milligrams.

Again, we'll get to this conversation, but I think that creates greater dependence because the longer the journey up, the harder the journey back down. And so I think it's prudent to keep this at moderate doses. And my experience is that if people are doing the other things that they should be doing, the low carb, the intermittent fasting, strength training, which is essential when you're on these medications, then you can cap those doses. You don't have to go to...

Morgan Nolte, PT, DPT (18:05.326)
Okay.

Paul Kolodzik (18:23.954)
doses. But again, for somebody that, I mean, for people that maybe just want to take a shot, and I don't think people really just want to take a shot, but sometimes they're being pushed in that direction by providers without correct support services, then you can go up to those high doses and get stuck there. So my use of this medicine is, again, at lower doses over a period of time. And you were talking...

You and I were talking beforehand, you know, the genie is out of the bottle. People are gonna use these medications. I have people that contact me and they are very focused on using the medications and I'll say, let's look at that, but stop. Let's think again, what the end's gonna look like. How are we gonna get you where you wanna be and how are you gonna sustain that weight loss for a lifetime after you're off the medication?

But I would think of a good ceiling dose more in the range of 1 .5 milligrams as opposed to 2 .4 milligrams. For people that are on Monjuro or ZepBound, the milligrams are different, but the highest dose on ZepBound or Monjuro is 15 milligrams. I like to keep people under 10, usually at 7 .5.

Morgan Nolte, PT, DPT (19:39.214)
Okay, that's so helpful. I really hope people are valuing this conversation as much as I am. I know I'm learning a ton. And you said that one of the risks of taking these medications at a higher doses is dependency. Now, are you talking about physical dependency like, you know, alcohol or a drug substance? Or are you talking psychological dependency? Can you go into that a little bit more?

Paul Kolodzik (20:03.378)
Yeah, it's more psychological dependency. You don't have withdrawal symptoms if you go off these medications. But the issue is weight regain. 60 % of the weight loss is regained unless there is a great focus on continuing lifestyle changes as you titrate down and off the medication. So there is not physical dependence, but you know.

you start titrating down, if you aren't doing the other things, the weight is gonna come back on and you're gonna become psychologically dependent on it, which is a bad place to be if either you're gaining weight or you feel, I can't go off the medication because I'll go back to the way I was. And that's why the whole lifestyle approach is so, so critical.

I mean, you want to be on this medication for a period of months, not for years or a lifetime. And so if you decide to go this direction, you need to go into this with your eyes open.

Morgan Nolte, PT, DPT (21:09.91)
Now, I had a question. You said that there's no withdrawal symptoms from going off of these medications. Have you experienced like rebound eating or increased appetite above their baseline when they stop with medications?

Paul Kolodzik (21:21.778)
Well, yeah, so I didn't consider that a withdrawal sentence, but the term that I hear over and over again is food noise. The food noise comes back. Yeah, so that is, but again, I think that's more psychological issue than what I meant to speak to and I didn't clarify, is actually a physical illness as a result of withdrawals.

Morgan Nolte, PT, DPT (21:31.246)
Yeah.

Morgan Nolte, PT, DPT (21:41.966)
It's okay.

Morgan Nolte, PT, DPT (21:46.382)
No, I would agree with you. I wouldn't classify that as a withdrawal either, but kind of a side effect maybe of withdrawal. What do you recommend people do? So let's kind of talk about some of those side effects. You mentioned most people have nausea. Most people have some degree of muscle loss and then the food noise, like the quiet when they're on the medication that might rise up again when they're off. What are some suggestions that you have for the nausea? Let's start there.

Paul Kolodzik (22:12.434)
Well, the best approach is a slow titration up, just to keep the doses low. You're gonna have less nausea at a milligram than you do at 2 .4 milligrams. And this is facilitating your effort to eventually get off the medication anyways. So keep the doses low. Medications could be used, the common one for nausea is Zofran.

But you know, it should be used in a limited manner because if somebody is having so much nausea that they need Zofran every dose, then that's probably not a good medication for them. So really the approach is to titrate it up very slowly. I would like to mention that I don't think anybody should go on the medication before they have an initial complete examination.

Morgan Nolte, PT, DPT (22:48.494)
Yeah.

Paul Kolodzik (23:03.89)
So in my mind, and again, this is something I've been doing for years, it includes a metabolic health assessment, which includes an assessment of insulin resistance. And I know that you know all about this, checking fasting insulin levels, calculating a level of insulin resistance. I of course am a big advocate of the continuous glucose monitors. I like to have people wear a CGM for a couple of weeks as part of that initial assessment before we even talk about medications.

And my preference is, though I have people, as you and I have talked, I have people come to me and they're focused on medications right out of the gate. And if they do the other things that we need to do to eventually get them off the medication, I will agree to do that. But my preference is to do this full metabolic health evaluation, use CGMs to guide a low carb diet, and then when you hit a stall maybe, begin to lean on the medicines in limited doses.

Morgan Nolte, PT, DPT (24:02.19)
Okay, there's so many follow -up questions that I have, so many directions that I want to go, but let's stick with the side effects first, and then we'll kind of keep going down my list. So how about muscle loss? When we're on these medications, why is muscle loss so common, and how do we mitigate that?

Paul Kolodzik (24:11.89)
Okay, all right.

Paul Kolodzik (24:20.754)
So when you lose weight, no matter what the avenue of you losing weight is, you're going to have some muscle mass loss. Okay. These medications seem to have a differential increase in muscle mass loss. Anybody that is on these medications, anybody should be strength training. You should not be on these medications without strength training to maintain muscle mass.

We all, I don't have to tell you this, but we all are losing muscle mass as we age. What is it, 7% % or more a decade? Yeah, do I have the numbers close to being right? Yeah, yeah.

Morgan Nolte, PT, DPT (24:56.27)
It depends on your age and your decade, but yeah, a significant amount per decade.

Paul Kolodzik (24:59.442)
Yeah.

Yeah, I mean, I can tell, you know, we all know that from our workouts as we age, that we're losing some muscle mass. And so you got to keep focused on the muscle mass and the protein. We're swimming upstream because we're losing muscle mass as we age. And for the women, men too, I mean, men have osteoporosis too, but you know, for the women especially, because they're more subject to osteoporosis, you've got to be strength training.

because the strength of your bones relates to your muscle mass size. If you have a bigger muscle mass and you're putting a little bit more strain on your bones with that muscle mass working out, then the bones react by getting stronger. So yeah, you gotta be stra, if people walk away with one recollection from this discussion, it needs to be, if I'm on these medicines, I gotta be strength training and I gotta be getting adequate.

Morgan Nolte, PT, DPT (25:46.798)
Yep, and I.

Morgan Nolte, PT, DPT (26:00.046)
And for people who need a resource for that, I'm going to do a shameless plug here. We have a YouTube playlist of strength training for beginners. There's a really good introductory video where people can watch to see how do I start training strength training? How do I reduce my risk of injury? And then over 30 tutorial videos with upper body core and lower body. It's all free on YouTube. You can go check it out with me explaining certain strength, like basic strength training movements, how to make them easier, harder, et cetera.

Paul Kolodzik (26:04.498)
Okay.

Morgan Nolte, PT, DPT (26:27.886)
because I'm a firm believer that everybody needs access to that information on how to start strength training and do it safely. So thank you for that. I completely agree. I think that that's a really important point to make that with these medications, it seems like we're losing more muscle mass than if we were just following a low carb diet or whatever dietary approach you want to follow to lose weight. I had another question here on the side effects, which was the food noise.

So that was the other side effects. When they stop the medications, the food noise returns. That's more of a psychological effect. So what do you recommend to your patients on how to deal with that?

Paul Kolodzik (27:03.794)
Ready?

You know, so as you know, I'm a low card person, you know, having studied this for years. I came to this through the emergency department. When I realized, you know, what gets all the press in the emergency department is the overdoses and the multiple traumas and the gunshot wounds. But what we see day in and day out every day is metabolic disease and the vascular complications, mostly from high blood sugar and the musculoskeletal complications from obesity. And so I believe...

that a low carb diet really is the way to go with this. So I think low carb is a lifestyle change. And I personally has experienced that and the majority, vast majority of my patients have, and it doesn't happen overnight, but you cut out food noise. I mean, you cut out thoughts of pizza and donuts and ice cream, and it gets to the point where it doesn't even become a consideration. It's not even in your mind anymore.

And so I think that is the best approach if there's medications are going to be used temporarily to cut out the food noises, just embrace a low carb lifestyle. We haven't talked in detail about this, but I know you believe in reducing insulin resistance. I think a low carb intermittent fasting approach is the best way to reduce insulin resistance. And I believe...

that lifestyle is much more sustainable than a calories in, calories out approach where you're just trying to do an energy balance thing. Low carb is a lifestyle and if you embrace that, preferably before and then while you're on these medications and after you're off these medications, you're gonna have much more success dealing with that food noise.

Morgan Nolte, PT, DPT (28:58.734)
100%. I can testify to that changing my own lifestyle. And a lot of patients, members, Zivli members have also adopted that lower carb intermittent fasting lifestyle. It has to be a lifestyle. So let me ask you this. If we're gonna, if the end game is to get off of these medications and we're beginning with the end in mind, why start them in the first place?

Paul Kolodzik (29:26.322)
So that's a great question. So I initially tried to avoid starting them. And I'll just speak very frankly to this. If I have somebody come to me, because they've heard that we've had success with patients and they are focused on medication, then I will agree to do that along with the other things as we talked about. Because I don't want to lose them to an internet program where they aren't going to get the support and they aren't going to hear.

you know, the advocacy related to the lifestyle changes. So I'll use the medications in two instances, and it's for a minority of my patients that I use the medications. And one is if somebody is absolutely focused and, you know, this may be a bad thing, but, you know, if they decide they're going to go somewhere else where they aren't going to get support, then I'd rather get them in the tent. I'd rather get them in the fold where they're going to hear about the right way to do it.

And then the other time is even with low carb intermittent fasting and strength training, people can get frustrated when they go through periods of stalls. You can have somebody that wants to lose 90 pounds and they can do great losing 40 pounds and then they hit a stall and they can get frustrated. And we'll dip our toe in the water of the medications during that period as well. So that's generally the two instances where I will.

Use the medicine that again, it's always limited doses and time limited as well

Morgan Nolte, PT, DPT (30:55.086)
limited duration. Yeah, because in my mind, I'm working with a client right now and add a weight loss stall. And whenever I get to my own, intermittent fasting is my go -to. Mixing up the fasting schedule, maybe doing an extended fast, that kind of stuff. So that just kind of came to my mind as we were talking. Okay, if we're beginning with the end in mind, but I think the perfect thing that you said is for some patients, it's a door in. They want that medication. They're going to get it somewhere.

Paul Kolodzik (31:03.858)
Yeah.

Morgan Nolte, PT, DPT (31:21.358)
I might as well give it to them so that I can provide the support needed to keep the weight off and so that I can reduce the psychological dependence that they might get if they're getting it on the internet at a dose that's not appropriate for them. All those things are so good to hear you say. So we kind of touched on this, but I also wanted to dig in just a little bit more. The question that I had was what criteria do you use to determine if someone is a good candidate for these medications?

versus just lifestyle changes. And it sounds like you want people to do the lifestyle changes, but if they really want the medications, then you'll consider it for them. But what if somebody is like, they have uncontrolled diabetes or they have extreme obesity. Those are the other two types of situations where I've heard physicians being more open to prescribing these. What's your thoughts on those two or are those not really the types of patients that you see in your practice?

Paul Kolodzik (32:19.698)
Well, I do see those types of patients in my practice. For diabetes, for blood sugar control, these medications I feel are appropriate. I still think though they should be used in the context of, while you're controlling your blood sugar, let's do the other things you can do to control your blood sugar. Again, low carb, intermittent fasting, which I got to say intermittent fasting gets embraced as a lifestyle just like low carb does. And...

You know, once you've done it for a while, you don't really even think about it. I'm sure that, you know, your listeners, many of your listeners have embraced that. But so with diabetics, it's appropriate. And then the other category is, I think there is a very obese category, you know, a BMI of 35 or higher, where they really have...

Morgan Nolte, PT, DPT (32:56.206)
Mm -hmm.

Paul Kolodzik (33:15.346)
And a lot of times those people, especially if they're middle -aged or older, will have some musculoskeletal issues as well. And I think trying to get them to a weight where they can then increase activity is a good thing. Because sometimes they can't work out. A lot of that I think has to do, we haven't talked about this, but if your blood sugar is high for a long period of time, you're getting that inflammation of your cartilage and inflammation of your joints.

Morgan Nolte, PT, DPT (33:33.238)
Mm -hmm.

Paul Kolodzik (33:43.986)
So the use of these medications to help control that blood sugar to maybe initially decrease weight, decrease joint inflammation and get people moving I think is a consideration as well.

Morgan Nolte, PT, DPT (33:57.614)
I just want to highlight something that you said. You use these medications minimally in your practice. You know, you focus so much on the lifestyle changes, which is all we do at Zibli. And what advice would you give to somebody who's maybe in their mid to late thirties, early forties, they have, you know, 30, 40, maybe like up to 50 pounds ish to lose and they want to take the medication.

but you see them not making the lifestyle changes. You see them eating junk. You see them drinking alcohol and excess. You see them not working out. What do you tell that person?

Paul Kolodzik (34:37.778)
Yeah, so, you know, fortunately, my patient population is self -selected. People come to me because they want to make changes. And we talk about, you know, those changes you have to make before we talk about medicine. And for five years, I did this without medications and, you know, would have people lose, you know, 60, 70, 100 pounds just with low carb guided by continuous glucose monitors, intermittent fasting and strength training.

So what we really wanna do is start with the lifestyle changes. So people come and they're completely focused on the medication. It's like, step back, let's do a metabolic health evaluation. Let's find out exactly where you are. Let's talk about the lifestyle changes. And just, if you need the medicine at some point, we can talk about that, but let's see what you can do without it. And then I think...

People have a foundational understanding of the lifestyle changes that are gonna be necessary for them to eventually get off the medication. And the flip, the other argument is maybe people, this is what the pharmaceutical companies want, and maybe some providers, it's just like, we're just gonna give you the medicine, you're gonna be on it for the rest of your life. I don't have patients come to me with that attitude. The people that come to me are interested in the foundational changes.

that will allow them to use the medication as a crutch. You know, crutches don't necessarily have to be bad. If I sprained my ankle and I need to use a crutch, you know, for a couple of weeks, then I can do that. But the plan is not to be dependent upon the crutch for the rest of my life.

Morgan Nolte, PT, DPT (36:19.438)
Right. Eventually you want your foot to get better. Eventually you want your metabolism to get better, your lifestyle habits to get better and then not need the crutch in the first place. All right. So I have a couple of other questions about, you've mentioned low carb, intermittent fasting, CGM, and I'm a huge advocate of all of those things. And I just kind of wanted to pick your brain on your philosophy with things. So where do you, so typically like what I recommend,

Paul Kolodzik (36:27.314)
Right.

Morgan Nolte, PT, DPT (36:45.646)
Let's learn how to eat first. Like let's learn how to fuel your body with the right amount of protein, carbs, fats, and then maybe fast like 12 to 14 hours a day before you progress your intermittent fasting. What's your philosophy on that?

Paul Kolodzik (36:56.434)
Exactly.

So again, the first thing I like to do is do an evaluation with the CGM. You know, you told me I could make a plug for the book at some point, so I'm going to use this opportunity. Okay, so this is the book, The Continuous Glucose Monitor Revolution for Non -Diabetics. CGMs, of course, were made for diabetics to dose insulin, but unbelievable tools in educating people about their blood glucose physiology. So I have people come in and the first thing we do is a full evaluation.

Morgan Nolte, PT, DPT (37:09.165)
Yes, anytime. Yes.

Morgan Nolte, PT, DPT (37:25.07)
Mm -hmm.

Paul Kolodzik (37:29.874)
where they wear a CGM for two weeks, we check a fasting insulin level, we get all the data, we consider their cholesterol, et cetera. And then the place to start, which I think was your question is, is, okay, based on that data that we've collected over a couple of weeks, what's the program gonna be? What is the macronutrient mix gonna look like? What's gonna be the carb limit? How much protein are you gonna need? You've never strength trained before? Well, let's talk about...

what a half hour, three times a week to start with bands looks like, or get a couple five or seven pound weights at home you can look at. Let's talk about what the fasting period is. You've never fasted? Well, okay, let's just do 10 hours overnight to begin with, and then we'll look at getting you to 12 and 14 and maybe 16. So I think the beginning is a full evaluation. And once you're on the medicine, the CGM data isn't gonna be as accurate.

you know, because your blood sugar is gonna be brought down. Yeah. So, I, you know, I had a number of new patients this week and it's like, let's get you a CGM. They came to me wanting to talk about medicine. It's like, let's do a CGM evaluation first. Let's find out what your fasting insulin level is because if we just start you on the medicine, then your numbers are gonna be distorted and you really aren't gonna understand your natural state and where you live to begin with. And in fact,

Morgan Nolte, PT, DPT (38:31.15)
That's such a good point, such a good point.

Paul Kolodzik (38:58.162)
When I use the CGMs in the first few weeks, I ask people not to change their diet, because I want them to see what maybe the largely processed food diet they've been eating has been doing to their blood sugar physiology. And then after that two weeks, we of course got plenty of time to correct that diet. So you start by gathering data and then, I mean, in summary, it's like,

a diagnostic period of time, gather data, okay, put a therapeutic plan together, and then institute that therapeutic plan. And I use CGMs to help guide diets as well long -term. Some people want to use them constantly. Some people want to use them intermittently. And then after that, if there's a consideration of maybe needing medicine at some point, we'll do that. So I think that's the best progression.

Morgan Nolte, PT, DPT (39:49.038)
Mm -hmm.

Morgan Nolte, PT, DPT (39:52.718)
Love it. Love everything you just said. It's so hard when you're wearing a continuous glucose monitor to not change what you're eating. It's really good data to help you reduce your carb intake. But I agree that it's helpful to eat that so that you get that immediate feedback about what those foods do to your glucose levels, because otherwise the effects of a high carb diet, of a processed food diet, you're not going to see those for decades. So I think the beautiful thing of a CGM is it brings the consequences into the present moment.

Paul Kolodzik (40:00.178)
It is.

Morgan Nolte, PT, DPT (40:21.678)
And I think that's very motivating for people to change their habits. Now, you mentioned that you use the CGM to help guide the dietary recommendations. Can you give us some specific parameters or information that you look at on somebody's CGM when determining say like their personal carbohydrate tolerance or threshold?

Paul Kolodzik (40:42.162)
I'm gonna tell you it's very individualized, because I have people that come in and they might have spikes that are, you know, they only go to 140 or so. This is spikes elevations in blood glucose after ingestion of a meal or carbs. And I have a lot of people that come in to me and they just, you know, the goal is I need to lose 40 pounds. And you put a CGM on them and they're spiking their sugars to 240.

Morgan Nolte, PT, DPT (40:44.366)
Okay.

Paul Kolodzik (41:08.978)
You know, they in fact, you know, have blown through the pre -diabetic phase without even knowing it and are diabetic. And so it's variable. So what I would say is it's kind of like a progression of goal setting, meaning, you know, if somebody comes in and they're spiking to 180, it's like, okay, let's try and keep your spikes for the next month under 150. You know, the other number we look at is averages. If your average for that person is 110, it's like,

Morgan Nolte, PT, DPT (41:14.958)
Mm -hmm.

Morgan Nolte, PT, DPT (41:33.518)
Gotcha.

Paul Kolodzik (41:38.45)
let's get your averages over under 100 for the next month. And then once they incrementally reach that goal, we set a more rigorous goal. But during this time, they're learning. They're learning about low carb. They're learning about internet and fasting. They're integrating strength training to decrease insulin resistance. I gotta just plug here. You know, strength training is...

You know, you're an advocate of it, but one of the reasons I love strength training is because the majority of Americans are overweight because of insulin resistance. And if you could increase the size of your muscles, you're increasing the quality and the receptivity of those insulin receptors on your muscles. Your muscles are soaking up more insulin, soaking up more blood glucose, reversing your insulin resistance. So I'm not anti cardiovascular training. You know, I, it's like, if you need to get on the treadmill or the bike, that's okay. But I actually try and, and.

have people meet the American Heart Association criteria for cardiovascular training. If you do that rigorously, you can do it in 75 minutes a week, meeting that criteria. And then because we all have limited time, let's spend that extra time, let's spend the workout, the majority of the workout time on strength training.

Morgan Nolte, PT, DPT (42:48.942)
You're speaking my language here. Okay. So one issue with CGM is cost. And I believe that Dexcom is coming out with a CGM that people can get in the States. Cause I think in Europe and I know in Canada, people can already get a CGM over the counter. But what are some tips that you have for people to reduce the out of pocket expense to get a continuous glucose monitor?

Paul Kolodzik (43:13.362)
So just a little insight into this for you looking for it. First of all, you gotta find a practitioner for now because they have to be prescribed that believes in it. I have patients that have asked their doctor, they said, you're not diabetic, you don't need it. Sometimes insurance company criteria is you not only have to be diabetic, but you gotta be on insulin in order to get it. But I have a tendency to use the freestyle habits. There is a coupon generally available.

Morgan Nolte, PT, DPT (43:24.91)
I know it's bad.

Paul Kolodzik (43:43.186)
that providers can utilize to get the first one free. So you can get a two week CGM generally the first time at no cost. And what I found, which is interesting is that even if you aren't diabetic, for most privately insured people, insurance can be applied and generally cut the cost in half. So the straight out of pocket costs for CGM is generally around 70 or $75.

What I found, if patients run it through their insurance, even if they aren't diabetic, if they just have insurance, generally it's around $35 or so. Generally Medicare and Medicaid again are not friendly to helping that patient population get those. But you can cut the cost by running it through insurance. And they are going over the counter and that's a great thing. But I actually have heard that they're gonna be about 90 bucks for two weeks.

Morgan Nolte, PT, DPT (44:29.262)
Yeah.

Morgan Nolte, PT, DPT (44:39.918)
assuming. I know. I was like, yeah, they're going to sell it over the counter for a big profit. And what I did was I asked my doctor to write one and she did. And then we don't have insurance. So both my husband and I, or me, however you say that, we're self -employed. And so we use Samaritan, which is a Christian cost -sharing program. And what we did was my physician called it into the Hy -Vee pharmacy. I'm assuming that this would work at Walgreens or C of S or wherever.

Paul Kolodzik (44:40.59)
Yeah.

Paul Kolodzik (45:00.594)
Yeah.

Morgan Nolte, PT, DPT (45:09.07)
And then each pharmacy usually has like a discount card that they can run prescriptions through. I'm just not sure if you can only use that discount card if you don't have insurance. So I always ask the pharmacy, hey, run that through your discount card or maybe see if GoodRx has a coupon. But I got one for $20 for a two -week CFM. Yeah, so I didn't know if you had any other tips, but all of those are for you.

Paul Kolodzik (45:28.434)
that's correct. Yeah.

No, insurance, yeah, actually the discounted card sometimes work even if you have insurance. So you just gotta work with the pharmacist to explore, is it cheaper through my insurance or should I use a good RX or other card or whatever? But yeah, if you approach that in a manner to just try and find the best deal generally, you can save some.

Morgan Nolte, PT, DPT (45:52.75)
Yeah, awesome. Okay. Well, I know that you have a book that you wrote about this before we get to that and what's in the book. Is there anything else that you think is really pertinent to add to this conversation about semaglutide or CGMs or appropriate use of semaglutide?

Paul Kolodzik (46:08.37)
Yeah, I think it's really what we've talked about, but to summarize again, it's begin with the end in mind. If you're going to use the medications, make sure you're doing the other things that are going to sustain your metabolic health for a lifetime. And I just, you know, very strongly believe that the tools we've talked about, again, low carb intermittent fasting strength training.

are critical. You know, historically, I think, you know, you look back at pictures in movies, photographs and movies in the 40s and 50s, you didn't see obese people then. And, you know, the food pyramid came in and we were instantly told to increase our carbs in our diet 25%. We replaced fat because cholesterol became public enemy number one. We replaced fat with carbs and then the obesity epidemic took off.

and the diabetic epidemic took off. And really, when you're talking about low -carb intermittent fasting, you're really just going back to the way Americans ate for generations before we were told to follow the food pyramid. And of course, the food pyramid came in, food processing industry jumped on board because there's nothing that's more profitable than combined sugar, refined grains, and seed oils.

and they have a long shelf life. And then the pharmaceutical industry joined in saying, if your cholesterol goes up, we got a medicine to treat that. And then unfortunately, I'm just gonna say medicine has changed too. When I was getting out of my residency, a lot of docs were still in private practice. And docs now, and I got a lot of friends that are primary care docs, they know I'm saying this, but they're relegated, they're largely working for health systems or sometimes even large public companies.

Morgan Nolte, PT, DPT (47:43.278)
huh.

Paul Kolodzik (47:55.186)
and they're relegated to 20 minutes with their patients. And in that period of time, you don't have time to talk about the things we're talking about here today or implement that kind of plan. You have time to adjust blood pressure medication or maybe add a new diabetic medication. You're just trying to, you know, it's like whack -a -mole. You know, we're just trying to, you know, stave off the disease. So...

I think, I guess globally, I'm kind of rambling here, but globally, I would ask people to find somebody to work with like you or like me that can help them talk about preventing and reversing disease rather than just treating.

Morgan Nolte, PT, DPT (48:36.59)
Awesome. man, this honestly has been one of my favorite interviews that I've ever done. I think this information is so pertinent and important to get out in this season where these medications I believe are being overprescribed or prescribed inappropriately. And I think that I hope people are listening to this conversation. If you liked this conversation, subscribe to the channel, subscribe to the podcast, give it a thumbs up, leave a comment, share it with a friend. People need to know this information.

And I know that you're so passionate about this that you wrote a book, which is a huge accomplishment. Congratulations on that. Can you let us know kind of what people can learn in your book and where they can get that?

Paul Kolodzik (49:15.858)
Yeah, it's really what we've talked about. Thank you for allowing me to mention again. Again, it's the Continuous Glucose Monitor to Revolution. It's the bestselling book on Amazon on CGMs. Again, for non -diabetics, pre -diabetics and non -diabetics to get a good handle on your blood glucose physiology. And then I'm also gonna mention for people that are looking for a doc to work with, either independent of the medications or with low dose, time limited medications.

My practice is primarily a telemedicine practice and I'm licensed in Ohio, Indiana, Florida and Arizona. And my website is metabolicMDs, just the word metabolic and mds .com. I appreciate you letting me mention.

Morgan Nolte, PT, DPT (49:58.122)
my gosh. Yeah. Thank you. Of course. No, I think you're awesome. I knew right when I got the email for you to come on the podcast, I'm like, he's a good fit. We've got to have him on this exact, this is the exact conversation that I've been wanting to have with somebody. And I'm so grateful that you shared your time and expertise with us today.

Paul Kolodzik (50:18.29)
And I'm very grateful for having that opportunity because the more people we can reach, the more lives we can change.

Morgan Nolte, PT, DPT (50:24.558)
Yes, awesome. Well, thank you so much and best of luck to you.

Paul Kolodzik (50:28.722)
All right, thanks a lot, Morgan.