Wegovy: I'm Baaaaack!

So yeah , I'm kind of preoccupied right now emotionally these days . My oldest daughter is our first child , is going to college . It's big . By the time this episode airs , we may be moving her into her dorm .

I have a Michigan scrub cap . You know such a great four years of my life and I just remember that time with such happiness and joy and fondness . And I know that she's going into this and I'm so excited for her . On the other hand , I'm going to miss her .

I mean , you know this kid's lived in my house for 18 , almost 19 years and you know she's not going to live in my house anymore . So anyway , if I do seem a little down or mopey a little bit , that's where it's from , I know , I know .

And so this comes from some data that was put out by Prime Therapeutics and Magellan RX Management , which is a Blue Cross , blue Shield , pbm pharmacy benefit manager , and honestly , I think the only thing PBMs may be good for these days is giving us some data about prescriptions , because all prescriptions go through them , so they're the data keepers of this .

They don't really serve much of a purpose beyond that , but anyway . So they presented this data and they showed that only one in four people who were prescribed Wegovy , and they only looked at Wegovy . They didn't look at Zepbound , they didn't look at Suxenda , only Wegovy . Only one in four people who were still taking it two years after it was prescribed .

They only looked at commercial plans . So no Medicare plans , no Medicaid or access plans . So they found some interesting things . Eighty-one percent of the prescriptions were written for women , but only , again , one in four people were still taking it . So of course , they're PBMs . They don't want to pay for these meds . They've got an ulterior motive here .

Their motive is hey , people don't like them , they don't work , they can't stick on them . They don't work , they can't stick on them and so we're seeing so little long-term compliance and so we should charge cash .

This is a glamour weight loss med and this is not something that we should ever have to pay for , because we could potentially lose money on these meds . That's their angle on this , but when we look at so , we have some other science surrounding this . So let's look at the Cermalt trial . This was Zepbound , not WeGovi .

20% of people either didn't have a great response or didn't tolerate the medication , and so I think that's what the science is going to tell us that four out of five people would be taking it if they kind of had unlimited access , because when you were in the trial , they just gave you the med .

So 36% of people stopped taking it at one year , 24% at two years . They also found 26% of patients changed drugs during their therapy , which again what we just saw . Last week we had Leslie on . She said I've been on all the meds , right . So we see this all the time . I have many , many patients who've been on every single medication .

So what I think this was all about was the PBMs trying to make a case that these are vanity drugs , that this isn't really what we're seeing with diabetes management , where there's much better compliance and people are very flighty and not using these meds for appropriate needs .

But really what we're seeing and Wego Govee was the worst during this study period in terms of shortages is we're seeing people can't get the medication because it's on shortage . Their prior auth is denying them . They're losing access . They're changing insurance .

It's this study , in my mind , shows access to care that a lot of people I'd say probably more than half of people in this who stopped taking it , stopped taking it not because they didn't like it , not because it wasn't working , but because they couldn't get it .

So just to cover half the people all drugs , every one of them cancer drugs , all of it . Wow , so just to cover half the people , right ? All drugs , every one of them cancer drugs , all of it diabetes drugs . Just to cover half the people who are overweight , we would have to double our prescription coverage spending .

So clearly this price does not sync with widespread use Again a point we've been talking about .

has to come down .

So I was heavy growing up , Wasn't very active and it just escalated from there and so I tried , oh gosh , multiple diets , I mean every fad diet . I tried it , you know , and then eventually had the lap band in 2009 .

And I lost some weight with that and then , you know , to be very honest , found ways to self-sabotage and , you know , gained weight back and can I stop you there for a second ?

yeah , you just blamed yourself for the lap band failing , but I nobody really was successful with the lap band you know , and I think it was a little bit of both right , because you know , I I think it was a little bit of both .

Because the lap band didn't work , because we discovered over time that it was a fairly ineffective surgery , that it was a fairly ineffective surgery and that when patients were regaining weight afterward , it was because the hormonal response that the lap band drove initially started to wear off over time , and this is a known physiologic phenomenon .

It's like if you were on a blood pressure medicine and it was working at first and then your blood pressure went up again , would you be like , oh , I just can't control my blood pressure , I failed my blood pressure up again ?

Would you be like , oh , I just can't control my blood pressure , I failed my blood pressure , I just , you know , squeezed down on my blood vessels too hard ?

It's very uncommon that I find a band patient . Now , you know , I think I've got one patient , you know who . We actually just recently did a band revision , but I used to do one of these almost every week .

Huh , and um , you know , my wake up call was you know , I'm a , I'm a daughter or , sorry , excuse me , I'm a dad . Now , I have a beautiful daughter , beautiful wife , and uh , you know , we were just to be very honest , you know , and transparent .

I was , uh , playing with her in the living room floor and , uh , you know , it was time to get up and I was huffing and puffing and , you know , one elbow on the furniture and the other elbow and by the time I got up , I mean , my heart rate was , you know , my heart was pounding , I was sweating and I thought , you know , this isn't good , you know , and

I'm too young to leave my wife and daughter behind time to make a change . So that was my wake up-up call . Yeah , that's my motivation .

I mean , yeah , it was almost instant overnight , like , oh , I don't need that platter of cookies in front of me in the office anymore , I can walk right by by it and not dwell on that .

It was like it was mind control in a great way , like I was able to , you know , not feel , like I needed , you know , carbs and snacks and all the you know terrible food to get through the day .

And so , uh , I was also learning a lot of techniques through the program and going to nutritional classes and , in my experience , like the 10 to 1 protein rule has been huge in my life and just being aware of what I'm eating and like how good and bad food can be , and so the Monjaro was really helpful for you .

We were going to have to deal with scar tissue and unwrapping the stomach and removing the band and all of that . So we got some weight off and we used the Monjaro to kind of bridge it . Were you diabetic or kind of ?

So I was up walking within a few hours of getting out of surgery and tried not to stop after that because I didn't , and I , you know our seven fishes dinner was .

We should right , you know , if we can use nutrition , exercise and the surgery alone and not have to deal with the shortages and continued use of the medication . That surgery alone is often enough for most people and that's one of the real advantages of that surgery , compared to a sleeve where we usually need to put it together with the meds .

So you've lost a tremendous amount of weight . How's life changed ? Can you get down on the ground ?

You just had Gatorade and you know I hear from a lot of patients they're afraid that they won't be able to and to me that sounds like a big annual thing , like something you look forward to a big part of your family life , and you weren't able to eat the food . Did you feel like you missed out on that ?

Because so many people kind of comment on I don't want to have to miss out on these big events that surround food , and that's true . There are big family events in our lives that that are , that are based on food . So how's that experience been ?

What you know , what are your thoughts on that , you know , was that I thought it was going to be , you know , rougher on me , because you know I love food .

So I was okay with it . I didn't feel like I was missing out because I wasn't .

Yeah , I think also that you know , the food is the side dish to these big family moments , and I think that's something people don't understand is we become so preoccupied , and a lot of it's just this intense drive for food that we all have , and it becomes preoccupied and the moment becomes about the food , when , in fact , the real value of the moment is it's

about the people in the room , it's about the family , it's about taking time , putting down your phones , talking to each other , sharing stories , laughing , you know , sharing memories . That's what those events are about , and the food is just it .

Really it's the side dish , and I think sometimes , once you pull away that drive for the food , you actually can experience the family a little bit more . Have you ? You agree with that ?

But you know , it's just like just being empowered to like , know the differences of , like the type of food and how we consume it and what its value is . Like . That's huge , yeah .

I know we worked on your performance nutrition around your races , so talk to us about how you've been able to combine , you know , all this new movement with your nutrition changes um , so I'm supposed to be done with my master's program any day now .

You know , during one of the classes I mentioned like I was doing homework and realized like , oh my God , like I'm still glued to this computer for four or five hours I haven't even moved . So I and just to be very open and transparent , you know I haven't been to the gym in like two weeks because I've been just right , you know , doing homework like crazy .

But I just need to get back to that . So I just want to get back outside and be a little bit more active in this wonderful triple digit temps .

And then , when that season of life starts to maybe shift , then you can shift your priorities and shift what those goals look like . So I'm excited for you .

And so what happens is as you get further out from surgery , the weight loss slows down a lot , and so a lot of people are kind of motivated by that weight loss in those first few months . But as it starts to slow down there's just not as much to motivate you and your goal . Weight isn't zero , right ?

So we're not going to keep losing and keep losing forever . So you have to find something else to use as a metric . And it sounds like to me you've used kind of five .

You went from 5K to four miles and now maybe you've got something else planned and looking at those exercise goals and those exercise achievements as the thing that is marking your progress , not the weight .

And I think that's a critical transition that really every bariatric surgery patient needs to make as they kind of get to the end of that first year after surgery .

I think we should start thinking about doing some things like that .

You know , literally within a few minutes you can be logged into one of your support groups , meeting with Zoe , and we also offer individual sessions , I think for $20 a pop . So that's a great price for a meeting with a dietitian , with a registered dietitian , certainly especially one as good as Zoe .

So yeah , as part of our membership , you also get discounted individual meetings . So if you're out there and you want to join the Pound to Cure Nutrition Program , please log in and sign up . We'd love to have you . So

, speaking of nutrition , zoe , what is our nutrition segment for this week ?

This is what we guide patients on immediately after surgery and also just as a general rule of thumb when you're looking at protein shakes and protein powders in general , rule of thumb when you're looking at protein shakes and protein powders in general .

However , in our navigating the grocery store session , I also help people identify this for protein , animal , whole food protein sources in general . This doesn't work for plant-based protein sources and this is not for non-protein foods , just to be clear .

So , basically , the 10 to 1 ratio rule is the ratio of calories to protein that you want to stay under , basically saying , you don't want the calories to be more than 10 times the amount of protein per serving . So there are 30 grams of protein . There needs to be less than 300 calories . There are 25 grams of protein less than 250 calories .

Less than 300 calories . There are 25 grams of protein less than 250 calories . So you'll identify the protein grams on the on the nutrition facts label , multiply it by 10 , check that the calories are less than that number . And what this does is . It does a couple of things . It accounts for maybe a higher fat content on some of those animal products .

It accounts for maybe a higher sugar content on some of those Greek yogurts that you know . It's actually a sugar bomb , you know .

So according to the 10 to one ratio rule doesn't follow it . But if you look at a 93 lean ground turkey , perhaps you have 21 grams of protein for that four ounce serving , but it's going to be 160 calories okay that . So that does follow the 10 to 1 ratio rule .

So specific steak cuts and that sort of thing don't know the nutrition facts on those off the top of my head , but that's the same idea .

All right , well , that's a great rule 10 to 1 . I will keep an eye out for that , but I hear a lot of patients talk to us about that . All

right , so let's move on to our economics of obesity segment and we're going to give you an update on the drug shortages . So we've talked about this in the past , but this is really a moving target . So we're recording this at the end of July in 2024 . And we're actually seeing a lot of movement in the right direction on the shortages .

And this is so important because we need these shortages to resolve in order to be able to put some pressure on Novo Nordisk and Eli Lilly to lower the prices . As long as there's shortages , let's be honest , there's really no impetus for them to lower the prices .

And so in the past , we've seen the Wegovy starting doses 0.25 and 0.5 , that there has been almost no access to . These have been almost impossible to get . We are now seeing a lot more access . We're seeing patients picking up their prescriptions without waits . We're seeing most pharmacies have these medications in stock .

They are still listed on the FDA website as limited availability , but what we find is that there's a wide variation of limited availability . Limited availability sometimes means occasionally a pharmacy doesn't have them . Other times it means no pharmacy has them and isn't getting them for another month or two .

And so what we're now seeing is the former , that these medications are relatively available . Can't guarantee every pharmacy is going to have it in stock , but most will . On the Monjaro and Zepbound front , we're seeing wide availability of the lower doses the 2.5 , the 5 , the 7.5 . And we're also seeing a lot of the 12.5 in stock .

But the 10 milligram and the 15 milligram are still unlimited availability and we actually are seeing patients struggling to find those doses and sometimes we're seeing patients kind of have to adjust their dose up or down a little bit from either 10 or 15 because they just can't get that medication . But probably two months ago nobody could get these meds .

Not any of them , not Zepound , not Wegovy , they just weren't available . Nobody could get anything , and so we've seen a huge change and we know that both companies have really invested in manufacturing and have increased their manufacturing capacity . My prediction is by the end of the year we should really see these shortages substantially improved and maybe end .

And again , this is going to allow us to put some pressure on the drug companies to lower these prices . So this is good news . We go . V is back .

And so I mean that's true of all medicine and we understand that , but with weight , it's really very you can really measure it very accurately and you can really see those differences . So a study that I've talked about many , many times comes from 2011 .

It's put out by a guy named Lee Kaplan , who really has done some excellent research , and a lot of what I talk about with a set point and lowering your set point and how that strategy works comes out of the research that he's done , and so he looked at 848 patients who had bariatric surgery and he found in those 848 patients , he found 13 first degree

relatives . He also found 10 pairs of patients who were living together but not related , most likely spouse , husband and wife and he looked at statistical modeling to determine which mattered more living in the same environment .

The idea is and you already just talked about how you and Matt were kind of shopping for shakes together , and that's very common is that husbands and wives tend to follow somewhat of a similar diet . Of course there's variation in that , but there is some commonality there .

And so we try to determine hey , what was more powerful of a factor for predicting success or failure ? Was it the relationship , the genetic relationship in those first degree relatives , or was it the cohabitation in those 10 people living together ? Guess who won , guess where there was the most correlation ? The genetics , absolutely .

So whether you pick two people who live together in the same home or pick two people randomly , essentially there was the same degree of variation between these two people . So essentially , living together with someone had no impact whatsoever on whether or not you're going to succeed after surgery .

So having that genetic relationship predicted that if one person did well after surgery , the other person was likely to also do well , and the same was true if they didn't do as well and lost less weight than expected . And so we know this is true for bariatric surgery .

We also know that bariatric surgery and weight loss meds GLP-1 meds work through fairly similar mechanisms . They work through this neurohormonal pathway , not so much by this anatomic restriction and malabsorption hormonal pathway , not so much by this anatomic restriction and malabsorption . We also know that pharmacogenetics is a major impact on how people respond to drugs .

So we know a lot of things that tell us that the answer to this is yes , that if a sibling and especially if it's a first-degree sibling , not a half-sibling was successful on one GLP-1 med , that your likelihood of being successful on the same med is high . Do we have strong data to know what those genes are , and has this been shown in the literature ?

Not to my knowledge , and so I can't give you an absolute yes because I'm not aware of any science on this , but I think , if we look at the foundation of everything that's similar to this in my mind , I would be shocked if any science on this .

But I think , if we look at the foundation of everything that's similar to this in my mind , I would be shocked if the answer to this turns out to be no .

question is from our Instagram on calories post-op , Because not reaching the protein goals can lead to a stall in weight loss . What can a person do to meet protein goals with a limited volume of food ? I have hypothyroidism but want to lose more weight with a limited volume of food .

And , in fact , just earlier today , we had our breaking through plateaus support group , and so this is some of the stuff that we were talking about . So , controlling what you can control , right , and that's what we're talking about here .

How can she meet her protein goals , which is something she's struggling to do , while being limited in the volume of food that she can eat due to the maybe surgery I guess that's not clear if she's had surgery or on the GLP-1s , but regardless limited volume of food . So we need to maximize that volume of food to reach your protein goals .

Let's just say your protein goal is 80 grams and you can only eat a little bit at a time . This is something that we talk about a lot , about .

How to help people get that protein in immediately after surgery is maybe adding an unflavored protein powder in with a Greek yogurt , or maybe that's adding that unflavored protein powder in with a blended bean soup , right , so you're kind of fortifying or amplifying that protein content for a smaller portion . And the same thing can be done with making a smoothie .

Right , you can put Greek yogurt and protein powder and peanut butter and all these wonderful things to really maximize your protein intake while minimizing the volume .

But it's a very , very common question , very common misconception , so glad we're able to clear it up .

If the patient got into powerlifting , bodybuilding , olympic weightlifting , sprinting they will need somewhere between 2,500 and 10,000 calories daily , depending on height , weight , exercise frequency and intensity . Of course , the new , smaller stomach pouch can expand . However , it can only expand so much .

It being reversible can really be detrimental to patients' mental health , as they'd have to limit their exercise that they love . I , for one , love the gym , so I know if I was overweight or obese enough or had a medical condition that would warrant a gastric sleeve or bypass surgery , I'd eventually fall in love with the gym .

According to the Caleric calculator I found online , when I'm most consistent with my exercise powerlifting , bodybuilding and sprinting my body needs 3,000 to 5,000 calories a day . For my goals , my maintenance calories are about 3,500 to 4,000 calories daily .

When I'm consistently active , I'm only 5'8" , so I'd be worried about not meeting those requirements if I had one of the two surgeries .

The stomach doesn't stretch out and cause weight gain . Everybody's stomach over time will stretch a little bit after these surgeries . That's just the natural anatomic change that we see as a result of the changes that we make .

That doesn't cause you to gain weight and people's ability to eat over time is really more about kind of getting to that new lowered set point where their set point and their actual weight become the same and they resume a more normal eating pattern . But it's not an anatomic stretching .

So , zoe , why don't you talk a little bit about the real essence of this question , which is the being able to meet that caloric need ? And can people who exercise vigorously ? Can people exercise vigorously after bariatric surgery ?

So it's that is going to be really challenging to do . Now we tend to overestimate how many calories we burn from exercise and we tend to underestimate how many calories we eat .

Let's be real , talking back to the awareness through the food blogging , awareness through the food logging right that we talked about with Martine , but ultimately that calorie need would require you to be exercising like crazy all day long and we want to view exercising as that set point , lowering as the opportunity to build muscle , as your opportunity to increase your

metabolism , help with that long-term weight maintenance , not view exercise as a way to burn calories right . And so having that mindset shift and even if you are powerlifting and you know , using bodybuilding style of training and sprinting , that's all great forms of movement and exercise .

I think that if somebody was genuinely concerned about needing a significantly higher calorie intake , I would really want to talk to them individually so we can dissect that and then make a more targeted plan if we do actually need to increase that daily calorie intake .

We just recently had Lori , who's , I think in her 60s an 18-mile run at altitude and I think there was a substantial climb in there . I've had a patient complete an Ironman , a real Ironman triathlon . So bariatric surgery has allowed these people to accomplish this . It has not held them back from accomplishing it .

And I don't see I think I wouldn't want anyone out there to say , oh , I want to do all these crazy intense things and so I would never have bariatric surgery , that's , that's not going to hold you back . The bariatric surgery is actually going to get you to be able to do those intense things .

I mean , you know , I get on that assault bike , you know that thing with a fan where you ride and and first of all , that thing is exhausting .

I mean it is so exhausting and you'll like ride like crazy for like a minute and you're like huffing and puffing , all out , sprint and at the bottom it says you burned 14 calories , right , literally one potato chip . You just burned one potato chip . You killed yourself for a minute . You're exhausted , you're sweating , breathing hard for one potato chip .

It just the calories don't add up , and so that's not how this is going to work , just like what your point that you made at the beginning .

You need to do to burn off a cheeseburger and it's like that's totally screwing with our mindset on how we should view exercise as a celebration of what our bodies can do , and not a punishment for what we're eating .

Another great episode , 37 , zoe . That's pretty good . I'm proud of us , yeah we're really cranking through these things and I hope you're enjoying them . If you are , please share them with somebody . Write us a review . The reviews help kind of bubble this up to the top so we can get this information out to more people out there .

We want to thank Ben from Bloom House Media for his videography and editing . We want to thank Martine for joining us today .

We want to thank Martine for joining us today and , if you are interested in seeing more of our content , we are on social media on TikTok , instagram and YouTube as well so hope to see you out there and drop us any questions or comments you'd like .