Anti-Obesity Medications: Part 2

Welcome back to another episode of the podcast. Today we're doing part two of the weight loss medications, and this is going to be a lot of the common questions that I get asked. I draw a lot of these directly from my social media and other places where people ask questions often, and I think you're really gonna enjoy today.

If you ever want to skip to a specific place in the episode, you know, maybe something is more or less relevant to, you know that in the show notes, I always have timestamps of kind of what is talked about at what time in the episode. So let's get right to it. So the

number one question that I get asked, All the time is, does the weight come back on if I stop the medications? And this is not unique to any single one of the anti-obesity medications. This is actually for all of them. If you use a medical intervention with the medication on the way down, What the studies show us the randomized controlled trials is that you do need to stay on the medicine for the weight to stay off. Now someone's gonna be out there and say, I kept the weight off.

And here's the thing I want you to, to to see. Number one, I would love for that to be true, right? I would love for there to be strategies where people can keep the weight off and not need the medicine. But the other thing too is it's not about keeping the weight off for a year or two. I want you to think five, 10 years out, I have doubts that the weight will be staying off without the medication if you used it initially.

We just see based on the studies that it's that slow creep back up to where the weight comes back to that weight set point where you started. I really like to stress with these medicines. They're just not a quick fix. It's not like, okay, it's a quick jumpstart. I take the medicine, I get the weight down, and then I stop taking them. It's a chronic medical condition that we're treating, and it makes sense that you wouldn't necessarily stop them.

And again, I'm open to future research and development here and seeing what happens over time, but. Generally, yes, there are strategies if you have to come off of it. Number one, sometimes if maybe for affordability or insurance reasons, things like that, you can't stay on one. You can either be changed to another one or changed to an oral option. And there are a lot of other things we can do as far as the diet to help. Implement where the weight doesn't come back.

But again, I see it being much more of a struggle than if people stay on the medications cuz this is, remember it's already a hard enough road, even with the medications. I see. People need to work very hard on this.

All right, the next thing I get asked about a lot is someone will say, I'm down x amount of weight, insert the number. 10 pounds, 20 pounds, 30 pounds. And they say, now it's not working anymore. So I just wanna, again, I wanna refine with some nuance, a few aspects here. I would encourage all of you, if you're on a weight loss journey to stop thinking about pounds lost, and instead, focus on your percentage of body weight that you've lost. And so I wanna tell you how to calculate that here.

But the reason why I'm gonna bring this up, even how to do the formula, how to calculate it for. It's because of the power of a 5% body weight loss. What we see across the board, no matter what weight you start at, is that 5% body weight loss. We see tremendous health benefits for you, and this does not matter where you start. And so in fact, I'm gonna do a whole episode on this, the. Power of 5%. You watch out for that. That's gonna come in the, probably in the coming weeks here.

But the reason I bring this up is that, I'm gonna give you an example. The other day I had a patient, she said, oh, I lost 20 pounds. And she was very unexcited about this. And it was my first visit with her. And so I said, well, what I like to always do first is figure out what percentage of your body weight that is. So we did the calculation and she had lost 10% of her body weight so far. That is phenomenal. 10% of your body weight that is. Really great amount of weight to get off.

We see so many health benefits with that. And then when she knew that, she was able to see, wow, I didn't even realize that cuz she had been focusing on, just the number, but not on these other things. So how do you calculate the total percentage body weight loss? So what I want you to do is you're gonna take the number 100 minus and you're gonna calculate your current body weight over your starting max weight, and you are gonna get the percentage that you've lost.

So for example, If you take your current weight divided by your starting max weight and you get 90, that would be a hundred minus 90. Remember, sorry, it's gonna be a percentage, right? So 0.9. So one minus 0.9, and you're gonna get the percentage that you've lost. Hopefully that makes sense. again, this is why you would work with the doctor. I'm usually not having people do these calculations on their own. I help them with it, but we wanna figure out the percentage that you're down.

What this is gonna help you with is realizing when you say, well, the medicine's not working anymore, maybe you have reached what that intervention is able to provide. So for example, like a 15% body weight loss is what we can typically see from the randomized controlled trials for example, the weekly medication would govi, which is the same as ozempic. We will see that so a lot of people, as they start to approach that, they will notice. the weight loss starts to slow down.

The weight loss loss might stop. Now, here is the key. It doesn't stop working. It's just that's where you remain. Okay? So that's like you have to watch the words that you're using because your, your brain is listening. It's not that the medicine isn't working anymore, it's that that's as far as it's able to take you based on

that. And then, the next question that I get is, okay, well if it stops working, Or, or people think that it stops working. Can I add another medication to it? Or kind of what are the next steps? The first thing I wanna say here is before we decide if that medicine is done, kind of providing what it can or not, now we can take. Evidence from research as far as what we could expect.

However, I always say don't get locked into those numbers because some people will lose less on it, some will lose much more on it. You don't know. That's called a hyper responder where you lose much more than expected, maybe even on lower doses. The first thing I do is that I look at is everything optimized before we make other changes? So let me give you an example. What is happening with, your protein intake? Are you actually malnourished?

I know a lot of people, they'll come from other physicians to me, and maybe that physician had no idea how to titrate the medication and that just every month they went up and the person was so appetite suppressed and felt so sick and felt so bad that they're extremely malnourished. They may be eating just you. Like eight, 900 calories a day. Well, of course you're gonna stop losing weight. You're greatly malnourished. You're undereating, and then the weight loss stops.

So it's actually looking at, are you eating enough? Are you having enough protein? Fiber intake? What's your hydration like, what's your movement like? So looking at all of those areas and really seeing, is there anything else we can optimize first? Now, let's say. We do feel like, yes, everything's rock solid and we've taken the medication as far as it can go, then yes, you can add on another medication.

This is actually extremely common in obesity medicine because remember, it's a chronic medical condition. And so we need to do the right thing at the right time, and that's gonna change over time. And so the one thing I wanna stress is if we add something on, it's not another thing in the same class, right? So if you're already on a GLP one medication, that's helping with satiety. and, you know, feeling enough things like that.

But then what you might notice is, okay, I'm doing all that, but I'm noticing more urges and cravings coming back. Now, remember this is not perfect, how our body's gonna respond to things. So the whole point is not to never have a food urge or craving, or never want food at a time when you're not hungry. It's, a lot of these things have to be worked through on a cognitive behavioral level, meaning those thoughts that we have because it's been very normalized in society.

even if you're not hungry, if you go to a birthday party, you have a piece of cake, or, oh, well, if everyone around me at night in the family is having some ice cream at night, I have that. A lot of these things, there's this fine line of discretion between. where is the medication actually needed and where do we have to do some other work on a more emotional front, on a thought work front, and kind of addressing that side.

But just to say, kind of looking at it, if you're having lots of urges and cravings and these things are very hard to control for you, then for example, something like Contrave which we talked about in part one, if you didn't catch that, maybe that can be added on again, if that nighttime snacking urges and cravings are really high for you. But again, there's multiple ways that we can come at this.

I really see long-term weight management as almost being sort of a chess game in the sense that there's this anticipation of what's coming up next, and this is why it's so helpful to work with an obesity medicine physician because, we are doing this all day long. And I can see when someone comes into me where their weight's starting, what their medical problems are, I can usually very much so anticipate what the next few months and year or two is gonna look like.

And everyone will have a slightly different course, but we really kind of know how far is this medication likely gonna take them, what else might be needed? And kind of figuring that out. And often when people come in to work with me in my clinic, so I have a, a, an obesity medicine, a direct care model where they're working with me closely. Things like that. And often people will say, okay, well how long should I expect to be working with you?

And I say, well, honestly, likely, very closely for about usually six months to a year. And then if you're stabilized and you're doing great things like that, then we kind of move into the maintenance period. And you kind of just do checks as needed. I always have a maintenance follow-up protocol for people so, Just to kind of give you one example of what's on there. It's sort of, Hey, if you put back on more than X, Y, Z weight, or if you're noticing X, Y, Z, then you call me back.

We do a follow-up appointment, we check in. We don't wait for 30 pounds to come back on to re-look at things. Right? But just to kind of give you a sense, this is navigated with time and it's, there's slow nuance and we want stability here and. all those answers don't kind of come overnight.

All right. The next thing I often see online, and I don't even think these are people that are listening right now, but a lot of people sort of shame the obesity medicine world for writing for medications off-label. And what I wanna let you know is that it's extremely common to write for these medicines off-label. In fact, throughout medicine. So about one out of four medications is written for off-label. This is common. A medication comes through. It's approved for one reason.

We find it's helpful for something else. I mean, think about the ex the example with Viagra. I hope you don't have small ears around right now. That medication was initially trialed to be a heart medication and they ended up finding that men had unprovoked erections. And guess what? It turned into use for other things.

This is very common where a medication will come out for one thing, we see it works for something else, and the company doesn't always necessarily go through and re-get FDA approval for the new indication. It's very interesting to me when the weight community is so shamed for this, when I really see that this is just bias and stigma showing up again because it's done everywhere. I see this everything. For example, neurology, headache, medications.

Often it's not the things that were approved for that end up being helpful because it can be so complex to control some really hard to control headaches. So it's just interesting to me how stigmatized and biased this area is when it's truly done in every single other area of medicine.

The the next area I wanted to talk about, just kind of a blanket statement out there. If you are a woman of childbearing age and you are on these medications, you really need a solid birth control plan. This is something that I find just kind of universally, my patients are kind of caught off guard by this, but it's really irresponsible if someone's prescribing these medications and you don't have a solid birth control plan. Number one, it makes no sense.

It's not logical that you'd be losing weight with a pregnancy. But number two, the bigger concern is that there's always a period where you don't know that you're pregnant for however many weeks before you find out.

And so that's really the concern, is that if you're on some of these medications, For example, I come back to the Topamax, that's topiramate, babies getting cleft lip and palate, things like that, that that's really something that we want to avoid and we can avoid that with making sure to have a good birth control plan. Something that I hear often is, well, I have had this struggle with infertility and so they think it's not possible to get pregnant.

What I wanna let you know, and we'll talk about this again in a future episode, fertility, potentially not always, potentially can go up with weight loss. And so that is why I don't care how many years you think that you've had an infertility struggle, I'm still gonna want a birth control plan to be in place just for your safety and just making sure that you.

The next area that I see often is that people will get the medication, but they have no comprehensive plan with that doctor. And so the problem that this creates is that you end up in a spot where you are actually worse with your health and if you've never done the medicine to begin with. If you kind of look at, if we really broke down like the four main pillars for chronic weight management, it would be nutrition movement. Possibly medications and behavior modification.

And so if you just get the medications and you're not really having someone that's coordinating it with you and questioning how you're doing and maybe making some suggestions, really partnering with you. The biggest example I wanna give here is that I've seen this with the Manjaro community. That's Tirzepatide. It's been written off-label this past year for weight manage. And hopefully the FDA approval's coming.

But what ended up happening is people would come to me after they'd had physicians that just kept going up on the dose monthly, and they hadn't been checking in with those patients. Those patients were so appetite suppressed and so nauseous and ill, and feeling bad that they were not eating properly, but the dose kept going up. So there was no reason for the dose to go up at that point. They already. you know that that was an inappropriate move to do that.

And then what ends up happening is they ate so little that then they didn't lose weight anyway. So then it sounds a little something like this, I'm on the max amount. I really haven't lost that much, and it was done in a way that is not beneficial. I really wanna suggest if you are going to go down this road where you do use a medication, that you really have someone that's checking in with you. This follow-up might look different for everyone.

Some of you, it might be physically in person in a clinic, others, it might be a virtual telehealth service where you're doing some video visits, you're able to message the doctor in between, but you're getting that check-in as far as what's happening with your weight, your appetite, your physical activity, your hydration. You have some accountability and. we can find the problems before they become disasters. And that's really the thing.

It's making this a health journey for you and not just quote unquote losing weight. So there's a big, big difference there. I really want to encourage you, we don't do medications in isolation because if we don't do all those other areas, I mean, I, I really. Recommend that people work with a registered dietician. And if you've had a bad experience, by the way, find another one. Because I have to tell you, there are amazing dieticians out there.

My opinion has been so changed in the past few years. I think I if, if you don't know me a long time, I. Worked with a dietician when I was pregnant years ago and had gestational diabetes. It was a horrible experience. She did not listen at all. She was giving me the same meal plans that she was giving. I I'm a vegetarian. She was giving me the same ones that some, like the whole thing had meat on it. I just, there was, that was the only reason I had gone.

I was like, Hey, help me to find some high protein options. Like I was open to learning. I wanted to learn and I just didn't get the help. Right? And so sometimes, Going to someone that although they have the credentials are just not that helpful. And then let's find you someone else. But I just wanna tell you, there's really good help out there.

There are people that don't force diet culture on you that are really understanding of meeting where you're at and helping you to solely improve from there. This does not need to be a wretched experience. The next question I get is about if someone has had a history of bariatric surgery, so whether that's sleeve or RNY, other things like that, can they take these anti-obesity medications?

And of course I want you to go talk to your medical team, your doctor, your surgeon, whoever it is, and you get that advice from them. But in general, the answer is yes. So this is a chronic medical condition and I always say, if there's the right medicine, the right tool at the right time.

So what's becoming increasingly common is if someone's going to get bariatric surgery, a lot of the times there's this huge pre-op period time, maybe even up to six months, where people need to have monthly dietician appointments and kind of prove different things during that time. And that might be a really great time as they're learning to balance out their meals.

So for example, if you're heading into bariatric surgery, You likely aren't gonna get approved if you're sitting there eating all at one time of day, that's not gonna work when you come out of surgery. So already beforehand you need to learn how to space out your meals, you know, showing compliance, maybe getting rid of some of those sugary sweetened beverages, things like that.

As you're doing all those things, I find that it's incredibly helpful already to start the medications because then your weight's down a little bit. Going into surgery, you likely still qualify for surgery, but then you can keep losing after that. And so it's really a matter of sometimes it's used before. Sometimes years out of bariatric surgery, people start to experience some weight regain, and then we add it in.

It's not always playing a part, but sometimes it is, but it's definitely not a reason why you're disqualified from using that, and so I would definitely make sure to disclose that to whatever physician you're working with. The last question on here, and this is the million dollar question, people always. They tell me where do I find a physician that I can work with?

That's like you, not everybody lives in Illinois, Indiana, or maybe my clinic isn't the right setup for everyone, and people really wanna know where to go. And what's so tricky about this space is that there's such variation. And that's frustrating, right? You want some evidence-based help. Maybe you want a certain way of going about things. Not every physician does things in the same.

So obviously I'll start first with my own clinic If you live in Indiana or Illinois and you are listening to this podcast who kind of like my approach, you wanna direct care obesity medicine practice, that means that it's me and you. We don't involve insurance in this. It's a. Set rate monthly. You meet with me, the dietician. I have a course that we do. We do weekly calls. There's a lot that we do. We do do a lot of mindset as well.

So if that type of approach, very anti-d diet culture, very supportive long-term. Coming from my own informed work. Having done this work myself, if that is something that's interesting to you, you can check out my clinic by going to rentier clinic.com, R e N T E a clinic.com.

And the thing I will say there too, this is just in general, if you wanna stay updated with, with these type of topics and sort of learning this type of information, the best way to stay up to date with this is to go to my clinic website, click on podcast, and write on the right hand side. You can subscribe to the obesity medicine podcast list and then that way just once a week you find out the episodes that are coming out, if there's ever resources, things like that.

That's where I would email people to, to get that word out. But, so that's my clinic, if that's something that's helpful to you. So right now it's all a virtual telehealth clinic, and starting in June, I will have a location in Lincolnwood, Illinois that's right in the Chicagoland area. So some people physically like to see me in person.

I know some of my patients, they just enjoy, they're doing telehealth right now, but some of them just want that monthly to come in the office to just sit down and talk. I genuinely really like telehealth and I know I hear from a lot of patients that.

They have been so stigmatized and biased with going into visits to be helped with this, that they actually enjoy, that they can kind of sit home in the comfort of their home and talk to me, and that they don't need to worry about getting on a scale in front of someone else that they don't know or if, the seating doesn't work for them or all these other things. There's just a lot that goes into this and they just appreciate not having to deal with that.

But real quickly, so if that does not apply to you, So, cuz there's obviously a lot of other states and scenarios. The website that I like the most now, sorry, background. There's no comprehensive listing for this. It's insanity. So if you go to abom.org, that's the American Board of Obesity Medicine. They list everyone that's board certified. So if you click on the top right, you click find a physician, you put in the two letter abbreviation of the state you're in. That's one way to search it.

There's also other ways, A whole list of the doctors come up. But here's the, the bad part. There's no link to websites or anything, so great. You know that the doctor's board certified, but you know nothing about their philosophy. You don't have links to clinics. It's, it's a mess. Right. And then the other one I'm gonna give you is great, but I wasn't even listed on there until, I think recently I submitted, but I don't even know if I'm on it But there's no like centralized directory for this.

And I think that's something that's so frustrating, but the one that I think is the best. It's obesity care providers.com and I will put the link down below. Again, it's obesity care providers.com. That's run by the Obesity Action Coalition. And what I love about this website, and this is why I would recommend this over any other one that I found so far. You can search by medical provider. You can search by bariatric surgeon.

Dietician, psychologists or psychiatrists, and again, depending on when you listen to this, maybe they've even updated that. I love the fact that number one, this is a registry where people have actively listed themselves and they also have to be in line with philosophies that support the treatment and understanding of this. I think that on multiple levels this is a good website to visit. It's also so much easier to search by location and things like that.

So let's see if I'm listed on this by the time, if you ever look at this website. And then, I hate to say this, but. You know, seeing different social media, seeing if there's any local physicians around you. I know more physicians are just realizing that they need a place on social media so that patients know their philosophy. So typically majority of my patients have come from referral, so I, I wasn't speaking out.

The reason I started to do a podcast and things like that is because I just couldn't stand the level of misinformation that was happening and people not getting the answers that they needed to go help. Help go find doctors and get help in whatever area, wherever they lived. So sometimes I find what's helpful about social media is that you can see, do you like their philosophy? Do you like how they describe things?

And then, of course it's different when you sit in a visit with them, but you sort of know some of the background. I find that that's very helpful. If you've been enjoying this, I would recommend that you subscribe to this podcast. Again, if you wanna get on the Obesity Medicine podcast list that, email list, you can do that with going to my website, rentier clinic.com. You click on podcast and right there on the right hand side is the list for that.

But coming up here, we have some really exciting things. I have some physicians coming on. I'm gonna do what I call like some lightning round with answering questions on common things that people want answers to. How to best treat constipation with these medications. How do you break a weight loss plateau? All of those kind of things. I'm gonna ask different doctors these questions so you can get multiple answers.

You can kind of get some different opinions on this stuff and we have some really great topics coming up, so I look forward to talking to you soon and have a great rest of your week.