Conquer Your Weight

Dr. Sarah Stombaugh: Before we get into the episode, I am thrilled to announce we are launching an online course, The GLP Guide. The GLP guide is a must have resource for patients who have been prescribed any of the GLP medications such as Wegovy, Ozempic, semaglutide, Zepbound, Mounjaro, tirzepatide, Saxenda, liraglutide. There are a lot of them and this course is available for anyone to purchase. We often hear from people who haven't been given much information about their GLP medications. No one has told them how to handle side effects, what nutrition recommendations they should follow, or what to expect in the longterm. And it can be really intimidating and simply frustrating to feel like you're alone in your weight loss journey. With the GLP guide, you'll get access to all of the answers to the most common questions for patients using GLP medications, not sure how to use your pen, struggling with nausea, wondering how to travel with your medications. We've got you covered for only $97 for one year access. This is an opportunity you do not want to miss. The course is launching on October 1st. For more information and sign up, please visit www.sarahstombaughmd.com/glp. You don't have to be on this journey alone. We are here to guide you. And now for today's episode, this is Dr. Sarah Stombaugh and you are listening to the Conquer Your Weight podcast. Announcer: Welcome to the Conquer Your Weight podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician and life coach, Dr. Sarah Stombaugh. Dr. Sarah Stombaugh: Hello everyone and welcome to this week's episode of the Conquer Your Weight podcast. Today we are talking about what will likely be my most controversial but most interesting topic. I get asked this question all of the time, which is should I or how do I wean off of my GLP medications? So GLP medications being things like Ozempic, and this could not come at a more timely time because there are so many changes happening right now in the compounded medication space. There are people who have been getting semaglutide or tirzepatide that are either no longer able to get those medications or very soon may not be able to get those. So starting to look at brand name medication options, maybe considering should I just stop the medication completely? Is it safe to do that? How do I wean off of or stop these medications? And I get asked this question a lot and it wasn't until one of my listeners reached out and said, Hey, Dr. Stombaugh, could you please do a podcast on this? And so the answer is yes. Here we are and doing it. And I have just been a little bit maybe nervous is the right word to record this episode and have this conversation because like I said, it's a pretty controversial topic about weaning off these medications. So let's dive in. Let's talk about these medications. Let's talk about how they are designed to be used and then talk about the sort of long-term plan and trajectory if you would like to stop or wean from these medications. So the reason that this is such a controversial topic is that when we look at the GLP medications, when you look at the studies of medications like Wegovy and Zepbound for the treatment of chronic metabolic disorder, chronic obesity, these medications are designed to be used in a long-term fashion. And the reason that makes sense is really similar to any other health condition. If we think about blood pressure, for example, and if you went into your doctor and they said, Hey, you have high blood pressure, we recommend taking this blood pressure medication, we're going to start you on let's say lisinopril. And you start at a dose, maybe titrate up to the place that adequately treats your blood pressure and you then go into the doctor, they do your blood pressure reading, you're like, oh my gosh, my blood pressure is 120 over 80 and you've been consistently taking the prescribed lisinopril, anti-hypertensive blood pressure medication. Your doctor would say, great, that means that we have achieved the adequate dose that is supporting your underlying hypertension or high blood pressure. Let's continue that medication. So we think about a lot of health conditions, this is actually the case. You find the dose that adequately treats and supports the underlying condition and then you maintain it at that. So similarly, when we look at the treatment of obesity, we look at how we are supporting it, we find the adequate dose of medication that supports our goals, and then we use that in a long-term fashion to help maintain the goals. And in the way that the person who has hypertension, they have that elevated blood pressure, their hypertension is not gone, it's just adequately treated. So similarly, someone who has Zepbound who is using Wegovy for the treatment of their obesity as their weight comes down, we don't say that their obesity is gone, we say that they've adequately treated it. Now that even can be a little bit controversial, but I usually will continue to have on someone's chart that history because it becomes important for the long-term use and insurance approval of these medications is that even as a person, let's say achieves a completely normal body mass index, they come into that range, that is normal. Their other health conditions are improving. We do want to make sure that they would continue to have insurance coverage of those medications. So we continue to document that history and the treatment history. So it makes sense that these medications are designed to be used in a long-term fashion and there are certainly people who desire to stop them. And one of the things that I feel very strongly about is that you or any patient, you are the boss of your own body. You get to decide what medications you are or are not taking it. And so even though I counsel every single patient for whom I prescribe these medications about the use of them, about the length of treatment, about what that looks like, and talk about some of the studies, and we'll get into that in a moment, I do also feel very strongly that you are the boss of your own body and if you desire not to be taking a medication, if you desire to be taking a lower dose of medication to wean off of the medication, it is my goal to support you in that. And then we can see does that continue to adequately support your goals, yes or no, and we can make decisions from there. So that piece is really, really important and I feel strongly that you get a say if you want to stop the medication. I will absolutely support any of my patients in that. Now, one of the things I do also want to say is that these medications are safe to stop abruptly. So let's say you have a major interaction, major side effect from the medication. You become pregnant for example, and you need to stop the medication abruptly. It is completely safe to stop the medication abruptly. So there's no sort of withdrawal effect, there's no sort of issue that comes up if you stop the medication that you may find that hunger comes back in a pretty significant way or appetite or cravings are coming back in a significant way, but there's no issue with it. It's not going to create any harm in stopping the medication abruptly. And so if you are in a situation where you need to, you've become pregnant, you've had a severe side effect from this medication, you need to stop it abruptly. It is 100% safe to stop that. I do recommend of course, having a conversation with your prescribing physician so that they understand certainly that they stop sending in new prescriptions or that if you are concerned that they're having a side effect, if it's not a severe side effect, it may be something that you're able to manage and decrease that side effect. And so if you're considering stopping a medication, I do always recommend discussing with your prescribing physician just to make sure that you're all on the same page, but it is absolutely safe to stop this medication abruptly if you need to. That being said, when we look at patients who are desiring to come off the medication and they don't need to do it in any acute way, they're saying, okay, I've achieved my weight loss goals. I don't feel that I need this medication anymore. What I typically recommend is that we wean from medication. And so let's talk a little bit about who is likely to have the best success rate of this. What do the studies show? So we look at studies of people who've stopped the medication. What does that actually look like considering why are you stopping? And then are you prepared for what will come up and do you have other mechanisms in place to help support you? So we look at the treatment of obesity and we look at the use of these medications. There's a really broad spectrum of patients who are using these. There are patients who are using them for a less significant weight loss. Sometimes it's described as almost cosmetic weight loss, but people who've struggled with 20 to 30 pounds of excess body weight versus people who've struggled with many hundreds of pounds of excess body weight. And the reality is, I can't make a blanket recommendation because the response to medication, the effectiveness of medication and what would happen if you wean off of or stop the medication, may look very different based on someone's individual physiology. So the people who are likely to have the best success in either stopping the medication or coming down to a lower dose of medication are the amount of weight that they have to lose. So people who have had less weight that they have lost and have gotten to their desired goal weight, if they have not needed to or lost as much weight, they are more likely to have success. The amount of time that they have been struggling with their weight is also important. People who've been carrying their weight for a shorter period of time, that sort of shorter on, shorter off type of thing is absolutely true. So patients who've gained a significant weight, maybe in response to pregnancy, for example, maybe in response to another health condition, I can think of a patient who is dealing with some pretty significant autoimmune concerns and had taken a lot of prednisone medication and had went from actually living in a completely healthy body, both healthy weight, otherwise great health beyond her autoimmune disease, and then all of a sudden finding herself with clinically significant obesity but had happened over a period of about a year that had happened to the length of time with which you've been struggling with your weight is really important. How much metabolic disease is there? So do you have sort of full-blown type two diabetes or pre-diabetes versus coming into your weight loss journey? Did you have normal metabolic health? Did you have a normal hemoglobin, A1C, no signs or very few signs of insulin resistance, for example. Those things can be really valuable. And then if there's been any weight cycling, so have you had a history of weight loss, weight gain, weight loss? Weight gain? People who have weight cycled may find that they have a higher body fat percentage for their total body weight and maybe people who have more metabolic disease based on their total body weight compared to someone who had not done that. Weight loss, weight gain, weight loss, weight gain. So people who have less weight to lose, have held their weight for a longer period of time, have less metabolic disease at baseline, less signs of insulin resistance as well as then people who have not had weight cycling. Those are the people who are likely to have the best success in weaning off of these medications. So we look at all of these medications and look at the titration schedule, whether we're talking about, and I'm going to use Zepbound and Wegovy because those are the brand names that are approved for the treatment of obesity, but Wegovy of course being the exact same as Ozempic, being the same as semaglutide. If we say Wegovy, Ozempic, semaglutide, those are all referring to the same thing. Similarly, if we're talking about Zepbound, that would also refer to Mounjaro, refer to tirzepatide, those being all the same thing. But I'm going to use Wegovy to refer to the Wegovy, Ozempic, semaglutide and Zepbound to refer to the Zepbound. We look at Wegovy, we look at Zepbound, and we look at the titration schedule. All of these are designed in this sort of stair-step fashion by which you would start at a low dose of medication, you can evaluate the effectiveness in four weeks later, move to the next dose of medication, evaluate the effectiveness, and four weeks later move to the next dose of medication, et cetera, to the top doses. So for Wegovy, there's five available doses of medication forze, there are six available doses of medication. It is important to note that technically when we look at what is FDA approved and studied as the maximum tolerated dose for Wegovy, that is the 2.4 and 1.7 milligram dosing. So those top two doses, forze, they did study three doses. They studied the five milligram, the 10 milligram, and the 15 milligram. So forze, there's the 2.55, 7.5 10, 12.5 15, and the five, 10 and 15 were studied for long-term treatment doses. So when we think about the titration schedule of these medications, of course everybody starts at a low dose of medication and they should be titrated up based on effectiveness, based on side effects. For example, one of the things that I find happening very frequently is that people are sort of rushed through their titration. So every four weeks they're moved to the next dose of medication regardless of how it's feeling in their body. So it's very common that I talk to people who are on a maximum dose of medication and they're feeling miserable, they're having a lot of side effects of medication, they're having a lot or complete appetite suppression and feel like eating like absolutely nothing. And then they just feel exhausted. They're tired, they're cold. They just have absolutely no energy because calories, food that we eat is actually energy for our body. And if we can completely suppress that, while our body of course is supposed to also be burning fat stores for energy can be really challenging to make sure that we're getting in adequate protein, for example, getting in adequate micronutrients. And so one of the best pieces of advice I have in general, even just in taking the medication, not necessarily in weaning off of the medication, is to take that titration on a very individual basis. There's no reason to rush through that titration. So you start on the lowest dose, what is the effectiveness of it? What are the side effects of it? Am I adequately achieving my goals? If yes, great, stay there. If not, then you need to move to the next dose of medication. But there's no reason to force that titration. And I have some people who are very responsive to this medication in the obesity medicine community, we call these people hyper responds or super responders where even in a long-term fashion, they do very well on low doses of the medication. And so I say that to say it's easier to wean off if you're not on as high of a dose, but also you may not require in general as high of a doses is a very individualized thing of let's find the dose that matches you symptoms and matches your needs and is helping you adequately and take that titration slowly. And if you're taking it slowly, sort of wherever you land, then in weaning we're thinking about stair stepping back from there. We're not thinking about if you've, let's say is that bound, for example, let's say you've gone to the five milligram dose, you took the 2.5, eventually moved to the five milligram dose, you stay there for a period of time. If we're deciding to wean off, we're only having to wean from the five milligram dose. Versus if you've gone up to the 10 or you've gone up to the 15, then of course you're weaning from a much higher point and that may be the dose that your body requires. But if it's more than you need, it's also why take more medication than you need, I guess is my point. So thinking about the titration schedule is also really important for if you are going to wean off of these medications. It's also really important to look at what did the study show. So there's actually a really great study from Eli Lilly, the medication, the manufacturer of the Zepbound medication. So that's the tirzepatide product called SURMOUNT-4. And in SURMOUNT-4, they answered this question, what happens to people who stop this medication? And what they did is for the first 36 weeks of the trial, everybody in the trial check medication, so they're brought up to the maximum tolerated dose of 10 or 15 milligrams of Zepbound, and then they measured what their weight loss was at that time. On average, patients lost 20.9% of their total body weight loss. At the 36 week mark, the patients were divided into two groups. One group stopped the medication completely, the other group continued the medication, and that was continued for an additional 52 weeks or a total of 88 weeks in the whole study. And what they found is that people who continued the medication on average continue to lose weight for an additional 5.5% and that people who stopped the medication on average regained 14% of their weight. Now, I'm not going to go through all of the math, but it's actually 14% of the lower 20%. And so what it ended up as is that patients were actually about on average 10% lower than their starting body weight. The important thing here is that 10% is just the average. So there are patients who had regained all of their weight and came back to their starting weight, and then there were patients who did actually maintain or nearly maintain their weight after stopping the medication. So there's a really broad response in what happens when people stop the medication with some people finding that their weight comes back, other people finding that they are able to maintain some or all of their weight loss. And it is those people that everybody's sort of holding onto that they'll be the ones who are also able to effectively stop the medication. But that may or may not be the case. There certainly are people who regain all of it. And so making sure are you taking this very individualized approach in trying to stop the medication? I think there's also really serious considerations about why are you stopping the medication, whether it's your insurance coverage or finance, whether it's side effects, whether you've achieved your weight loss goals, why you are stopping is also going to contribute then to how do you move forward. So we think about, okay, maybe I've achieved my goal weight, I'd like to stop the medication, or I'd like to wean off of the medication. I like to assess what is the readiness? Have there been other changes? We've been working on nutrition, we've been working on movement, we've been working on sleep, maybe working on hormones as someone's in their perimenopausal years, for example, have we adequately addressed all of the other aspects of their life in order to make sure that those are adequately supported? Do you have those mechanisms in place? Those patients who have those other mechanisms in place are going to do better compared to the person who's simply been just eating less food of their starting diet, for example. So we think about doing this in a very gradual way. Sometimes we will space out the dosing. So these medications are designed to be taken once per week. What we can do is try taking them every 10 days, for example, or every 14 days in taking it that way, does it continue to support suppression of the appetite? If that's going well, then we decide to take a step back at that every week dose level, and then we could do another 10 to 14 days at that lower dose and then take a step back. And this can be something done very gradually over the course of many months or over the course of years. Are you doing other things in your diet that are helping to promote satiety or fullness? Are you getting adequate protein? Are you getting fiber? Do you really want to rely on those two things in order to help both fill the stomach as well as signal that fullness signal in the brain? Are you getting plenty of hydration and adequately pushing that throughout the day? Being mindful of avoiding ultra processed foods, things with lots of sugar, things with lots of flour, things like chips and snack foods, for example, that don't create fullness and satiety in the same way that protein and fiber will for you. Are you getting exercise? Are you moving your body regularly? We know that movement, particularly for weight maintenance is really important. Strength training of course, important as well. I recommend this certainly during the weight loss journey, but especially during the weight maintenance journey. Are you adequately supporting your muscle mass in order to help support your metabolism as well? This will be one of the most important things. Thinking about mindful eating and behavioral strategies. Do you have those in habit? Are you aware of when you're likely to eat? Even if you're not hungry? Do you have plans for the work dinner or for the vacation or for other times that can be really challenging for you? Are you interested in taking other medications? So particularly if you've had to stop maybe because of pregnancy or you've had to stop because of insurance coverage, you may not be yet into a place in your journey where you're ready to stop the medication, but you just have to. And so are there other things that we would consider? Would we think about medications like Metformin, for example, bupropion, topiramate. These are something you should talk with your physician about, especially if you're having to stop these medications. Are there other things we can do phentermine even to help support your underlying goals in order to continue to support the body, even if it's not the GLP medication? And then just knowing that you can revert your course at any point, especially if you've decided, Hey, I want to wean off this medication. Maybe get partway through the wean and decide, actually, you know what? I am feeling really good at taking this lower dose of medication, or I'm feeling really good at taking it every couple of weeks. For example. We can take a really individualized and custom approach, but if you find that, oh gosh, the weight is coming back, I really liked the way that I felt on a higher dose of medication, there's absolutely nothing wrong with going back up on the dose. That's absolutely an option. I worry that the conversation about stopping GLP is driven by our underlying society obesity bias that so many of us have internalized and feeling like in some way that we have failed and needing to use these medications. But the reality is these are life-changing medications that especially when used in combination with nutrition and movement and sleep and all of the other pieces, all of those behavioral changes can make such a huge impact in our health, and it makes sense in a lot of cases to continue to use them as a tool in the longterm. So if you've been struggling with your weight, if you've been wondering, oh my gosh, I'd like to stop these medications or I'd like to try my doctor's not supportive of that. If you live in Illinois, Virginia, or Tennessee where I'm licensed to practice medicine, I would love to support you in your weight loss goals. I'd love to work through that with you. You can reach out to me at www.sarahstombaughmd.com. Thank you guys so much for joining me today. This was in response to one of our listener questions. If you ever have questions, shoot those to us at our email address info@sarahstombaughmd.com. I would love to address your questions in the podcast. Thank you for joining us today. We'll see you all next week. Bye-bye.