Episode #151: Are GLP Medications Right For You?

GLP-1 medications like Wegovy, Zepbound, Ozempic, and Mounjaro have changed the conversation around weight loss. But with so much noise online, how do you know if these medications are actually right for you?

In today’s episode, I break down the science, the safety, and the real-world factors that determine whether GLP-1 medications could be a helpful tool on your weight-loss journey.

In this video, you’ll learn:

• What GLP-1 hormones do in your body
• How these medications help with appetite and metabolic regulation
• Who is a good candidate—and who isn’t
• Why GLP-1s work incredibly well for some people but not for others
• How to avoid going on a dose that’s too high for your body
• The essential habits you still need even with medication
• How to know if the medication is working for you

Ready to get started on your weight loss journey? We’re now enrolling patients for in-person visits in Charlottesville, Virginia and for telemedicine throughout the states of Illinois, Tennessee, and Virginia. Learn more and get started today at https://www.sarahstombaughmd.com

Are you taking a GLP medication? We are thrilled to share we are offering an online course, The GLP Guide, to answer the most common questions people have while taking GLP medications.

To sign up, please visit: www.sarahstombaughmd.com/glp

Transcript

Dr. Sarah Stombaugh:

This is Dr. Sarah Stombaugh, and you are listening to the Conquer Your Weight Podcast.

Announcer:

Welcome to the Conquer Your Weight Podcast, where you will learn to understand your mind and body so you can achieve long-term weight loss. Here's your host, obesity medicine physician, and life coach, Dr. Sarah Stombaugh.

Dr. Sarah Stombaugh:

Hello everyone, and welcome to this week's podcast. This is a super exciting episode because it actually marks the launch of our new YouTube channel, and I'm so excited to share that with you all. So if you have been listening to this podcast and you're like, why is Dr. Stombaugh not on YouTube? I finally am. All the same things that you love on the podcast will also be available on YouTube. So certainly you can hear those here on the podcast if that is your preferred option. But you could also head on over to our YouTube channel, Conquer Your Weight. We'll put that link on the show notes if you're interested in that. And I would love to have you over there. Or if you know someone who's interested in YouTube, please share my podcast with them, share my YouTube with them. I would absolutely love for you to support me in that way. Thank you for being a listener. 

And today we are going to talk about GLP medications. Over the last couple of years, more and more people have been talking about Ozempic, Wegovy, Zepbound, Mounjaro, all of these GLP medications. And you might be wondering, should I be taking one of those? Am I a good candidate for it? And that is what we're going to talk about today. Who is and who is not a good candidate for these medications? I am Dr. Sarah Stombaugh, board certified obesity medicine physician, and I'm excited to dive into this today with you. When we think about the GLP medications, they've actually been around for a while, about two decades at the time of this recording, for the treatment of type 2 diabetes. It was in the last decade that we saw them then approved for the treatment of weight management, but really they've only taken off in popularity over the last couple of years. You'll recognize names like Ozempic, Wegovy, Zepbound, Mounjaro. These are all within the GLP family. There are some other medications, older medications, particularly things like Victoza, Saxenda, that you might hear about as well. 

Now, all of these medications work very similarly to one another, and they do all work on the GLP receptor. Some of the medications, like Zepbound and Mounjaro, actually had a second receptor as well called the GIP receptor. So they are a more potent medication. But what is the GLP receptor? How does that work in your body? Now we know that we have GLP receptors located in a lot of different parts of our body, predominantly in the gastrointestinal system, as well as in the brain. A lot of times when we think about appetite regulation, we think about our stomach, like, oh, my stomach's growling or I'm, you know, I'm hungry. And that certainly can be true, but a lot of our appetite is regulated from within the brain. So a lot of our hunger and satiety pathways are regulated within the brain, and there is a gut brain signaling that happens that helps to regulate before and after meals about hunger signaling. So GLP works within that brain on that hunger and satiety or fullness pathway. It also works in the gastrointestinal system. And we see things like change in GI transit time. So food that you eat sticks with you a little bit longer. This can also create some of the common side effects like constipation. We're not going to go too much into side effects as part of today's video, but don't worry, you can find that in some of our other videos coming soon. 

And with side effects like constipation, but the GI transit time, such that food that you eat stays in your stomach longer, it sits with you for a longer period of time. And so you may feel full for a longer period of time, you may find that you get full more quickly, and you might find that you get hungry less often because that food is sticking with you a little bit better. There's also an improvement of insulin sensitivity, and this is very meal-dependent in that when you eat, your body has a more efficient response with insulin. So you're able to process away that energy for later. And all of these things work together such that people who are taking these medications will feel that they are less hungry less often. When they do eat, they feel fuller for longer. And a lot of times, hunger is this physiological and psychological combination event, and people will experience that they notice a difference in terms of their desire for food, their cravings, their urges, that type of thing. And so there's these changes where they're feeling less hungry less often, getting full more rapidly, and having less cravings. You hear a lot of people refer to that as food noise. So just not constantly thinking about food, planning the next meal, you know, making all their like, oh, when is it going to be time for me to eat that next thing? So it could be really mentally freeing to be on these medications. 

Now, officially, who is supposed to take these medications? Now, of course, all of these medications are approved for the treatment of type 2 diabetes. They are also approved, or some of them are approved for the treatment of weight reduction. So let's go through some of the different medications. Interestingly, Ozempic, which has been the poster child for this movement, is a medication that is FDA-approved for the treatment of type 2 diabetes. Now, just because it's technically for diabetes does not mean it cannot be used for other things. And of course, we find that it is often used for things like PCOS and weight management as well. This medication is also approved for weight management as Wegovy. So Ozempic and Wegovy are exactly the same medication as one another. Those are both semaglutide medications. 

Zepbound and Mounjaro similarly are identical to one another. Zepbound and Mounjaro are both tirzepatide products, with Zepbound being the weight version and Mounjaro being the type 2 diabetes version. So all of these medications are can be very effective and are used commonly for the treatment of type 2 diabetes. They are also officially approved for the treatment of chronic overweight and obesity. Technically, the definition of this looks like a BMI of 30 or higher, or a BMI of 27 or higher with a weight-related comorbidity. Those can be things like high blood pressure, high cholesterol, arthritis, polycystic ovarian syndrome, a lot of different conditions can meet that comorbidity criteria. So if you do have another comorbid condition, you can certainly talk to your doctor about that. And beyond that, though, what we know is that there may be people who do not traditionally meet either of those criteria who may actually be pretty good candidates for the medication. When I'm talking to a patient and trying to decide would they be a good fit for the medication, what we're looking for is one, do they have extra body weight? You know, have they gained weight over whatever period of time, whether it's a long period of time or over a certain life change? So very commonly for women after menopause, for example, noticing that they're having weight gain and when that is associated with metabolic disease. When I say metabolic disease, I'm looking at things like blood sugar, cholesterol, where our weight is stored, as well as things like blood pressure and that. 

So when we think about blood sugar, a lot of times people are looking at hemoglobin A1C. This is a measurement of your blood sugar over three months period of time. It can tip into type 2 diabetes category with an A1C of 6.5 or higher. Prediabetes is in the range of 5.7 to 6.4, and then normal is anything less than 5.7. What I really commonly see though is that patients may fall into this criteria where even if their hemoglobin A1C is normal, let's say it's 5.6, it's kind of right on that border. They've been seeing elevated blood sugars over a period of time. And we'll go back and look at their lab work and we'll see things like their blood sugar, fasting blood sugar can range between 60 and 99 typically to be considered normal. But we'll see that their levels are consistently like 90, 95, 98, 99, maybe starting to tip over into the low 100s, you know, 102, 104, some of these low level elevations or higher, but within the normal range. And that can be an early sign of metabolic disease. A lot of times we might do additional lab testing, like an insulin level, for example, and looking at what is your fasting blood sugar, what is your fasting insulin level, that can give us an idea of how insulin resistant you are and how effectively your body is processing energy. So that is one side of metabolic disease. We might also be looking at cholesterol, and we can see this in different parts of the cholesterol panel. Honestly, our LDL, which is typically thought of as the bad cholesterol, may be elevated. We may see elevated triglycerides. We may also see a low HDL, which is HDL is typically our good cholesterol. So some of those things may also point to changes that are indicative of metabolic disease. 

We may just start to see things like elevated blood pressures. So either officially being diagnosed with hypertension or just having those kind of borderline readings that have been creeping up over years. Where we store our weight is really important as well. So visceral adiposity, this is the weight gain that happens predominantly centrally. So it's weight gain in and around our organs. This is weight that is more indicative of metabolic disease compared to weight that is subcutaneous or sort of soft fat on our body. So having, let's say, cellulite or fat on your legs is not as big of a problem, or actually, not even may not be a problem at all compared to visceral adiposity or that weight that's happening centrally in and around your organs is a sign of metabolic disease. Associated with that, sometimes we'll see elevations in liver enzymes. This is something that doesn't always flag abnormal on blood testing that you might have done, but there may be levels that are in the higher range of normal. And this is something you should discuss with your physician, especially if you're seeing some of these other things go along as well. But with that visceral adiposity or that central weight gain, you'll see things like noticing even if your body weight is the same, that you're storing weight in different places, you might notice that you're needing to change clothing size, particularly a pant size, if you're measuring waist circumference, that may be elevated. So someone who falls into this category, even if their BMI does not traditionally meet that 27 threshold, let's say their BMI is 25 or 26, they may still be a really good candidate for GLP. So it's that metabolic disease that I'm really looking for when I'm making the decision of is this a good medication? Could this really be supportive for someone? 

Now, there are people for whom GLP medications are not a good idea. We know that there are certain disease states like MEN2 syndrome or medullary thyroid cancer, that if you have a personal or family history of these, you should not take any of the GLP medications. In rodent studies, they did see an increase in the size of the thyroid C cells, which in humans would correspond to the two medullary thyroid growth or concern for medullary thyroid cancer. This is more of a theoretical risk, but because of this known growth that happened in the rodent studies, it is recommended for people with that specific medullary thyroid cancer or MEN2 syndrome. Family history should not take these medications. Now, that does not apply to people with other thyroid cancers. So there's other more common types of thyroid cancer that are not associated with this as well, and maybe perfectly safe and often are perfectly safe to use GLP medications. So it's important to know you know, if you have a second cousin once removed that had papillary thyroid cancer, that is not a problem. You could absolutely use GLP medications if you're otherwise an appropriate candidate. Also, these medications, because of the known change in GI motility and side effects that can happen, they were not studied in patients with a history of severe gastrointestinal disease, including gastroparesis. So someone who already has a history of gastroparesis should not use these medications. We do know that people who have a history of acute pancreatitis, particularly if it's been recurrent and there's not been a clear reason for why that has occurred, we do want to be careful and proceed with caution about using these medications. And patients with that history may not be the best candidate. We also know that patients who are pregnant or planning to become pregnant in the near future would not be good candidates for the medication. And then certainly there may be other situations where you and your doctor decide if it is or is not a good fit for you. So when we think about, okay, it sounds like I might be a candidate for these medications. Should I get started? What are some of the things that you'll want to consider before you start taking a GLP medication? I think, especially in the time that we're in right now, cost has to be a factor. We know that there is improving insurance coverage for these medications, but the cash pay price for these medications can still be pretty costly. And when we look at the treatment of these medications, they are designed for long-term use. 

And so we do want to make sure that when you think about that cost investment, that's one you feel comfortable making for the long term. I think one of the things that's been really exciting is over time we've slowly seen decreases in the cash pay prices. We've seen improvement in coverage for these medications, but it is still a consideration. Do you have insurance coverage? What is the cash pay price? Is that in line with your budget? Making sure you understand that. I also really want people to think about what long-term looks like as well. I think in our diet culture, there's so much conversation around like being really intense in a program for a period of time and then you're done. I'm really looking at using these medications in a long-term fashion. Now, we'll talk about it other times, what it looks like for short-term or intermediate term use versus long-term, but really these medications are designed for long-term use. And so if you're going in saying, hey, I know I just want to take this for three to six months, you may not be the best candidate for these medications. I also don't want to think of them as any sort of, you know, rapid weight loss journey or any sort of quick diet plan fix. When I think about someone's weight trajectory, I want to make sure that they're losing weight slowly and really big air quotes on that because it doesn't actually have to be slow, but sometimes we want the weight loss journey to go really, really quickly. We have this desire of losing two, three, four pounds per week. And the reality is that rapid weight loss can have very serious consequences. For one, are you able to adequately fuel your body? If not, your body might feel really run down, like feeling fatigued and tired all day long, feeling cold, just feeling like you have absolutely no energy if you're not able to fuel your body. So you don't want to have appetite suppression to the point where you're just not able to eat anything, even if that could potentially cause rapid weight loss. For one, that will slow down quicker than you think. And for two, you're going to feel miserable during that time. A lot of times as well, when we think about what was the interval of time in which you gained the weight, it doesn't usually happen overnight. 

Typically, if we look back, someone gained weight over the course of many years, sometimes even many decades. And I'm not saying it has to take decades to lose the weight, but there's no reason that we need to rush the journey as well. For the average person, losing weight in a trajectory of one to two pounds per week, it's going to be a really safe and effective way in order to do that, to feel good, to feel like you're able to adequately fuel your energy levels. And if you're trying to rapidly lose weight and then discontinue these medications, I'm worried that you'll just be set up for a situation where it's just another failed diet or another kind of yo-yo up and down that can happen. So slow is good. Slow, again, major air quotes, one to two pounds per week is often an excellent trajectory. And as you lose more weight and you now have less weight on your body to lose, you might realize that the trajectory slows down even more. And that's okay. Your body is not meant to just consistently every single time you step on the scale to be lower and lower and lower. You are going to see that things slow down eventually. And your trajectory is not always going to be linear. So there will be some ups and downs in the journey. But when we take a step back and say, you know, let's say like on the first of every month and you look sort of month over month, have you lost at least four or five pounds over that month? If the answer is yes, that is awesome. And you can absolutely keep going with that trajectory that you're on. So that is what I'm typically looking for. But all in, lose a lot of weight quickly, and then stop the medication, that is absolutely not the goal. So we do want to make sure that someone is adequately prepared for what is the healthiest way to support themselves during this weight loss journey. Alongside of that, we're thinking about GLP medications as just one tool in the toolbox. These medications are really working to support the underlying physiological changes that can make weight loss hard. When you have chronic metabolic disease, you're dealing with insulin resistance, you have those elevated blood sugars, elevated waist circumference, some of the stuff we were talking about before. Even if you were doing everything in line with your goals, it can make it really challenging for the body to release weight. 

And so GLPs become this amazing medication that allow all of those changes you've been trying to make to finally take effect in a way that feels really empowering, to feel like, okay, all these things I'm doing, they're like finally, finally working on my body. And they are just one tool in the toolbox. We still want to be thinking about nutrition. We want to be thinking about movement. We want to be thinking about the behavioral changes. Very frequently, I meet highly educated people who could write a book on nutrition, but it's not about knowing. It's about what does your day-to-day life look like? What are your family obligations, your professional obligations? Are you traveling? Are there vacations? Are there family and friend gatherings that are throwing you off track? And working through those behavioral changes is going to be one of the most empowering things, and honestly, one of the most important tools in finding long-term success. So as you think about starting a GLP medication, committing to the entire journey, committing to exploring what is my relationship with food, how am I handling some of these different situations and working through it beforehand, making a plan, and then reflecting back after you've had some of these different situations, reflecting back and seeing, okay, what was successful? What would I have done differently? So thinking of it as one tool in your toolbox and not the whole shebang, I think is really important as well. Now, what is true is that there are many people who we are learning are really good candidates for these medications. 

And if you are listening to this and thinking, hey, like that might be me, I might be a really good candidate for this medication. If you are someone who is looking for a doctor to support you, I do see patients in person in Charlottesville, Virginia. I also do telemedicine throughout the states of Illinois, Tennessee, and Virginia. And if you're like, oh shoot, I am not in one of those states, how do I get the support that I need? Couple of great options for you. We do have an online program called the GLP Guide. This is a video program to help support you as you get started and navigate your GLP journey. I'll also recommend for you to see a board-certified obesity medicine physician. You can go to the ABOM, the American Board of Obesity Medicine, and you can search for a physician near you who is certified in obesity medicine to help support you in this way. Thank you so much for joining us. We'll see you all next time.