How GLP-1 Medications Work: Treating Obesity as a Disease

In this in-depth episode of Hormones & Hope, Dr. Chhaya Makhija is joined by obesity medicine specialist Dr. Sarah Stombaugh for a thoughtful, evidence-based conversation on obesity as a chronic disease and the evolving role of GLP-1 receptor agonists in long-term weight and metabolic health.

Together, they unpack why obesity is not simply about willpower, how genetics, hormones, inflammation, and environment intersect, and where medications like GLP-1s fit into a comprehensive treatment plan. The discussion goes far beyond prescriptions—covering lifestyle integration, realistic expectations, ethical concerns around compounded medications, and why repairing our relationship with food may be the most important intervention of all.

This episode is a must-listen for patients, clinicians, and anyone seeking clarity amid the noise surrounding modern weight-loss treatments.

Dr. Sarah Stombaugh is a family medicine physician and diplomate of the American Board of Obesity Medicine. Graduating from Creighton University Medical School and completing her family medicine residency at University of Chicago, Dr. Stombaugh practiced outpatient primary care in Evanston, Illinois before moving to Charlottesville, Virginia with her family.

Upon moving to Charlottesville, Dr. Stombaugh opened a private practice weight loss clinic, in which she sees patients in-person at her downtown Charlottesville office and by telemedicine throughout the states of Virginia and Illinois.

In addition to her clinical work, Dr. Stombaugh is the host of the "Conquer Your Weight" podcast. Through this platform, she shares valuable insights, expert opinions, and practical advice on weight management, contributing to the well-being of a broader audience. Dr. Stombaugh believes in empowering both individuals and the medical community in order to promote an evidence-based approach to the treatment of obesity.

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Download the Free Guide 'Your Health on GLP-1' Here:

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Transcript

SPEAKER_00 0:00

So the first question, true or false, obesity is a chronic disease, multifactorial, and only low-caloric diet is not an answer. So true, it is a chronic disease. Yes or no? Is inflammation a major driver of obesity and metabolic dysfunction? Yes, but I would say it's a chicken and the egg. True or false? Genetics play a bigger role in obesity than most people think. Yes, true. One non-negotiable lifestyle habit that you emphasize with all your patients. Welcome to Hormones and Hope, a podcast where we bridge science and wellness to help transform your health. I'm your host, Dr. Chaya Makija, or you can call me Dr. Chaya, a triple board certified endocrinologist and lifestyle medicine physician and founder of Unified Endocrine and Diabetes Care. Each week we dive into the powerful intersection of clinical medicine and real-life lifestyle strategies to help you feel stronger, live longer, and show up as your most vibrant self inside and out. So let's get empowered. Hi everyone, hello and welcome to another episode on Hormones and Hope. Another exciting day for me as I introduce you to one of my favorite physicians in obesity medicine world, and that's Dr. Sarah Stambull, visiting us virtually from all the way northeast. That's Virginia, Charlottesville, Virginia. And um, I just got to know that we have a great connection. She went to medical school at Creighton University and uh same town in Omaha, I spent uh uh two years or three years during my fellowship at University of Nebraska. So great, cool connection here today. The reason I know Sarah or Dr. Sarah is also because of our common interest in obesity and GLP1 medications, and I've learned a lot about her work in evidence-based field. She educates physicians and her patients as well as the community. She has an amazing course on her website, uh, which is a GLP 1 guide. So if anyone of you really wanted to dive in and get like a weekly or a daily course about what GLP 1 medications are, that's a great place to start. And I learned something today that Dr. Sarah released her uh new YouTube channel, which is called Conquer Your Weight. And she's all an amazing host for her podcast, Conquer Your Weight, for almost, what, two years? Yeah, almost three now. Three years. Okay, very, very cool. So she's double boat certified, uh, family medicine physician and obesity medicine physician. She's also a speaker, and I am delighted to learn so much more about obesity, about uh medications, pharmacological interventions, and lifestyle today with Dr. Sarah. So welcome, Dr. Sarah.

SPEAKER_01 2:50

Thank you. Thanks so much, Dr. Mikija, for having me. I'm really excited to be here and sharing with your audience today. Absolutely. Yes.

SPEAKER_00 2:57

We always love to learn more. So, Dr. Sarah, before we start, you know, I just wanted to share that in the last four or five weeks, we've had a few physicians. I myself have done a few solar podcasts on weight management, obesity, what's the pathophysiology. But you're the first one who is also involved in community education and actually creating these uh legit courses. So I would love to understand what was your passion, like why uh this field of medicine and why did you, why is this your niche? So something about yourself, something fun, and uh something about your passion.

SPEAKER_01 3:34

Yeah, absolutely. So the interest in nutrition, weight, obesity is actually one of the biggest drivers of why I chose to go into medicine in the first place. I grew up in a really small community in rural Illinois. And most of my community members, including most of the members of my family, really struggled with obesity in a way that I didn't fully understand and I didn't feel like had the answers to. Even actually, then going through medical school. A big reason why I chose primary care was it felt like a place that I could help support obesity and help support patients in this preventative type of way. And even through that, realizing I wasn't quite getting the answers. And so I've been on the quest to really help to answer that question for patients when they'd say, Hey, doc, how can I lose weight? I felt like the tools in my toolbox were, well, just eat less and move more. And I knew that it was not as simple as that. And so I've been on this quest to get the solutions to that. And it's led me to where I'm at right now, which is both looking at the medical side of things, thinking about metabolic health, how we can support that through medications and nutrition interventions and other lifestyle management, but also really the behavioral piece of things, which I think is really a crux of how we support people in ongoing weight management and health.

SPEAKER_00 4:52

Yeah, absolutely. You know, the comprehensive part of it and uh and it's not just one aspect of medicine. Yeah, I love the quest. So this podcast is hormones and hope. And what we usually leave our audience is with, you know, evidence-based science tools as well as uh lifestyle intervention tools. And that's what we're gonna learn today from you, Dr. Sarah. But before we start our deep dive questions, we have a fun way of um answering a few questions, which is a rapid fire round, usually six to seven questions and one-word answer. Or if you think that really needs an explanation, maybe one sentence. And then if that needs an elaborate explanation, we can get into the deep dive related to that topic. So you're ready? I'm ready. Okay. So the first question, true or false, obesity is a chronic disease, multifactorial, and only low-calorie diet is not an answer. So true. It is a chronic disease. Right or wrong, GLP1 medication should never be used for purely cosmetic weight loss.

SPEAKER_01 5:53

I will say wrong, except for I will we'll define maybe a little bit later what is cosmetic versus actually metabolic disease.

SPEAKER_00 6:01

Number three, true or false. Most people regain weight after stopping GLP1 medications because obesity itself is chronic, not because a medication failed. Yes, true. Yes or no? Is inflammation a major driver of obesity and metabolic dysfunction? Yes, but I would say it's a chicken and the egg. True or false? Genetics play a bigger role in obesity than most people think. Yes, true. Okay. And number six, this is related to GLP1 medications, short-term or long term. Should they be used for short-term or long term?

SPEAKER_01 6:38

Generally long term, but I think that's a topic we could dive into a little bit more.

SPEAKER_00 6:43

One non-negotiable lifestyle habit that you emphasize with all your patients. Honestly, I think it's our relationship with food. And so not just what we're doing, but why we're doing it. Thank you. That's one of the first answers that I've uh received in uh the lifestyle habit. So thank you so much. Yes. All right. So now we are ready to get into the explanations. So, how about this? You know, we could gear this discussion with weight per se. Like, what is this concept of weight gain versus weight loss, and why do we have obesity now as a chronic disease? Interestingly, uh, while we are recording this podcast, I think WHO released their guidelines on obesity just yesterday or day before yesterday, giving us a basic stamping for the world that this is a chronic disease. So, knowing that, can you walk us through? Like, what's the pathophysiology? What's the background? What's happening? Why are we in this era of obesity being one of the epidemics?

SPEAKER_01 7:45

Absolutely. And I think this shift in how we're looking at obesity as a chronic disease has been really significant, as you said, in the last couple of days. But even over the last couple of years, if you think where we were a decade ago, I think almost everyone in the general community, as well as the medical community, looked at obesity or looked at excess weight as more of a cosmetic issue, did not always see or tie that to cardiac or other metabolic disease processes. And the shift in understanding, I think has been really powerful. And we know that obesity is a chronic disease because there's so many different factors that influence it. As we talked about in the rapid fire, there's a huge amount of obesity that may be tied to genetics. Estimates will range between 40 and 70% is genetically determined. Now, there's a lot of factors there, both our genetics and our epigenetics, meaning how our genes are altered by the environment. And that even starts in utero. So when you are a baby in your mother's stomach, or say stomach, right? Just like in, you know, layman's terms, but you know, you're a baby growing inside of your mother. And even that environment can alter our genes. Certainly, as we live and work in our world, our genes can be modified sometimes by the foods we eat, environmental toxins. A lot of that's not fully understood at that point. So a lot of this we know can be a factor, but I think, you know, give it two or three decades and we'll be really understanding that in a much more comprehensive way. So there's this genetic part. There is nutritional and the environment that we surround ourselves in, both in terms of the access we have to food, the just day-to-day routines that we have, what our preferences are, the way foods are manufactured now, as opposed to a more whole foods, traditional way of eating that can be harder to access, especially in a very busy schedule. We live in a culture that's a lot more sedentary than it was in the past. And then there's a lot of other things in with our relationship with food, our day-to-day behaviors, as well as our chronic relationship with how we eat, traumas related to other things by which we're using food as an escape. So there's all of these different pieces. But I think the biggest challenge then is that once we have obesity, it can be this very cyclical thing. The body has a set weight theory and a lot of different theories by which our body, once we're at certain weights, can really resist weight loss. There's a lot of metabolic and hormonal factors that contribute to this. You know, sometimes we think about fat mass as this like blob that sits in our body. But the reality is that fat is a varied metabolically active tissue. And so having fat mass on our body changes hormone signaling, like insulin, for example, like leptin. So we know that insulin regulates our energy storage and having excess adipose tissue contributes to insulin resistance. So our body is spending more time storing energy and makes it more difficult to release energy. We have leptin resistance. Leptin is our fullness hormone, as you know. And people with obesity do not experience fullness in the same way. So we have all these factors then where your body is not wanting to release weight. And then when you try to lose weight, your body is like, oh no, are we in a famine? And adjust those in order to help maintain out a weight, even if that weight is really higher than desired. So when we think about the treatment to obesity, it's really this multi-pronged approach where we're thinking about lifestyle intervention, like nutrition and movement and sleep and behavioral modifications, but we're also thinking about what is the underlying metabolic disease here? And do we need to support that with medications and or something like bariatric surgery?

SPEAKER_00 11:27

Yes, yeah. So it does get complex and it's not like one patient will just have one reason or retiology and that could be fixed. It's uh and you know, you beautifully mentioned about genetics and epigenetics, which we are understanding uh more and more, especially the epigenetics now. So, you know, when you uh when we were talking about the rapid fire, you mentioned about the cosmetic weight loss. What I wanted to discuss is how do you approach patient care? So, you know, when we define obesity in medicine, it's you know BMI of 30 and above, and then there are grades of obesity. But how important is body mass index for you when you are seeing your patients, treating your patients, or they come to get some help related to their metabolic dysfunction or weight?

SPEAKER_01 12:13

So BMI, I think, could be an excellent population-based screening tool. And certainly when someone has an elevated BMI, we may be looking at other factors to determine hey, are we concerned about this? You know, there's always the example of someone who lives in a very muscular body, in a very athletic body. Is that BMI a problem? And maybe not, right? They may live in a very muscular body and have perfect metabolic health. And so I will look at someone's weight, I will look at their BMI, but thinking about things, for example, like body fat mass, looking at things like waist circumference, when we start to dive into labs, either previous labs that a patient has done or a new set of labs, and usually both, we're looking at things like glucose level, especially fasting glucose. We might be looking at hemoglobin A1C, I'll look at a fasting insulin level, especially in the HOMA IR calculation, where we're looking at both glucose and insulin and their relationship to one another, and looking at things like the cholesterol panel, the liver enzymes, things like blood pressure. And I think one of the things that's interesting is that I sometimes have patients come to me that perceive that they have a cosmetic weight loss goal. So, for example, a woman who's in her perimenopausal or early postmenopausal years and uh probably another topic for another time, but can have insulin resistance associated with those hormonal changes. And maybe she's noticed a 10 to 30 pound weight gain during that time. What's really interesting is that even if she sort of sees that and our culture perceives it as a cosmetic weight loss goal, when we dive into other pieces, we may see signs of metabolic disease. Like there may be elevated cholesterol, elevated fasting blood sugar, elevated liver enzymes. They increase waist circumference, for example. And so there's other factors that we're looking at. Now, we do want to make sure that doesn't mean that GLPs are the answer. There may be other tools, even lifestyle, for example, that can help someone to approach that. But I don't think that just the BMI of 30 or higher or BMI of 27 or higher with a comorbidity needs to be the strict cutoff for these medications. I certainly have and do often prescribe these medications in patients who may have a BMI of 25 or 26, for example, based on other individual criteria. Certainly, we also didn't play, talk about the role of when we look at different ethnic groups, they may also have obesity at lower BMI thresholds. So we want to take those into consideration as well.

SPEAKER_00 14:40

Absolutely, yes. And especially the Asian and South Asian population, where uh we still have obesity and type 2 diabetes as their main chronic diseases, too. Thank you. So because you are one of the GLP1 gurus, according to me, can you now explain? Because we have a lot of information about glucagon-like peptide receptor agonists, uh, these medications. And uh, just to put that concept, it was uh what, 2005 or 2007 when for endocrinology we started prescribing them for type 2 diabetes. And uh now it's almost two decades. But in the last four or five years is where they are out on social media, uh in the internet world, in literally every household discussion. So it becomes even more important for physicians like uh you and me to share what's the actual evidence. How can we use it clinically and how would it be meaningful for our patients in the right manner? And uh, you know, what I tell my patients is that let's get the goodness of the medications and how do we prevent the common side effects or how do we uh avoid those in the long run while you're getting the benefits? So, can you walk us through like a full toolbox basically? How do you initiate this discussion for FD-approved medications for obesity? Even if you had to walk us through like a patient example, that would be great. And how do you integrate after incorporating these uh prescriptions the lifestyle aspect of the care?

SPEAKER_01 16:12

Yeah, absolutely. Well, I think the GLPs have been really life-changing for so many people because they work on the underlying metabolic disease. We know that we have GLP receptors in the brain that help to regulate some of the appetite signaling. We also have GI receptors or GLP receptors rather in our gastrointestinal system, our GI system. And so we see that in a stomach with gastrointestinal movement, we see it with the pancreas. And so the effect is both direct as well as indirect in terms of how it's supporting and regulating weight loss. And I think as you described, age being one of the tools of the toolbox is really where the magic of these medications comes in. And so in my practice right now, I just do obesity medicine. So I'm not doing primary care at all. And so by the time people have come to see me, a lot of times they have been working on many of the lifestyle factors and a lot of times have had some success, but feeling like either, you know, not enough success to clinically support them in enough weight loss to see improvement across other health conditions or improvement, you know, in their body and the way that they're functioning, for example. And so we're thinking about layering on these GLPs as another tool in the toolbox. And so when they're looked at in that way, they're just they're amazing. You know, so often I find people who've been working on nutrition, they've been working on movement, they've been working on sleep. And there's still things a lot of times that we can optimize from those standpoints. But even with all of those things, it just doesn't feel like it's taking effect in the body in the way that we would expect it to. And this is really due to that underlying metabolic disease. We talked earlier about the role of fat mass and how adipose tissue has a lot of hormonal signaling. So medications like the GLPs really help them to be that tool that allows all of those other changes to finally take place, you know, in the way that we want it to. And so sometimes that means patients are starting early on in my practice. As I mentioned, they've been working on some of those lifestyle things and we continue to make adjustments as they are on the medications. And sometimes we're also starting with lifestyle and then layering on GLP, you know, months into the future, depending on one's individual journey. And it's amazing. I think one of the things that I do that's maybe a little bit different compared to the FDA label is I'm very intentional about the dose of medication that we choose. Of course, everybody should start on a low dose of medication unless they're switching from another one. But we start at that low dose and then see how is your body feeling? How is your body responding? When we're determining the effectiveness of the dose, we're thinking about how well are side effects managed, if you're having any. And then from an effectiveness standpoint, both how is it feeling in your body as well as what are you seeing in terms of the weight response and weight loss response there? Because if we are able to help you lose weight while adequately fueling your body, that's the goal. You know, I don't want someone to be eating nothing. You know, occasionally we will encounter patients or people will reach out who are like, okay, I'm just eating a handful of crackers every day. That is not the goal. We want you to feel like your hormonal signaling is regular, such that you're able to eat in line with your goals, but still adequately get protein, still adequately get fiber, still feel energized that you can move and feel good throughout the day. And so a lot of times my titration of these medications will be really slow. Not always. You know, we're looking to that individual patient to see how they're doing. But commonly I'll have patients that say on very low doses of Zet bound or Wagovi for periods of time before we're making that titration. And we're only titrating when side effects are not well managed, if someone is or are well managed, but they're no longer seeing response in terms of weight loss and feeling like a lot of that increased hunger, cravings, urging for food is coming back.

SPEAKER_00 19:54

This is going to be a little controversial, but what do you tell your patients, or if you get uh questions about, you know, why don't you prescribe compounded uh GLP one? So what's your perspective towards that?

SPEAKER_01 20:06

You know, it's really interesting because compounded medications on a whole play a very important role in medicine. Compounded medications basically just mean taking an active pharmaceutical ingredient and making it in a way that it individualized to a patient and for some sort of patient need. So I've had many situations in the past where compounded medications have made sense for people. You know, someone has an allergy to a component of a medication. Like I had a patient who had an allergy to corn and their medication contained a cornstarch filler. So they had a compounded medication to help, and it was like a blood pressure medication. Or another patient who was on a feeding tube and required a liquid medication that was not traditionally available in liquids, those were made in a compounded pharmacy. So there's a lot of reasons and far beyond those that compounded pharmacies are used. I think recently what we've seen in the GLP medication space is that compounding has turned into this mass manufacturing and there is less regulatory oversight over those products. So there's a question from the API, the active pharmaceutical ingredient, where is that coming from? Is that safe? Is it actually what they say that it is? I think this is one of the biggest concerns is that you want something that is a 100% chemical copy. You do not want a 98% chemical copy. You want something that is identical to you. You want it not contaminated, you want it made in a sterile environment, such that you're both getting a product that is safe and efficacious. And while I think that is certainly theoretically possible, the mass manufacturing of it really compromises the risk of these products being both ineffective as well as unsafe. And I think one of the biggest changes, especially now, you know, we're recording this in December of 2025. We've seen so much shift in terms of the cash pay options that the cost savings for compound medications is no longer. There, certainly not in the way that it may have been even a year ago. And so the argument for compounded medications is becoming less and less over time. And why get a compounded product? Would you could get the brand name product for the same? Or in some cases, I've seen it even at you know lower or better prices for the brand name product.

SPEAKER_00 22:20

Yes, absolutely. I totally echo that uh sentiment and the way you explained it. Yeah, thank you so much. It was uh very clear that you know why we have compounded medications in the field of medicine and uh what's the role here for GLP1. So, you know, one more a rapid fire question. I think you mentioned about the gray zone, the short-term versus long-term use of uh these medications, a GLP1 receptor agonist. So, in your patient care, how do you discuss or bring about the discussion as you're treating your patients that okay, there is a possibility that this could be a short-term plan for you or a prescription versus this is bound to be ongoing for your care. Absolutely.

SPEAKER_01 23:00

Well, I think one of the things that's most important here is that recognizing the patient is the boss of their own body. And so if someone is coming into a discussion and they're like, I only want to use this for a short period of time, I'm talking about that and exploring why that's the case. And generally talking about these medications in a long-term capacity. We know that there are a very small subset of patients that may do well on shorter term dosing and shorter in the, you know, six to 18 month range, very few people are going to take these medications for two or three months and find that they've, you know, adequately had their weight loss goals. When we look at the use of these medications, because they're working on that underlying metabolic disease, it is not necessarily, once that's no longer in your system, it's not necessarily going to have an ongoing effect. We do know that the lifestyle piece is very important, but it's talking about all of these different tools. And it's when you're doing all of those tools together that patients find that they have the best effect. Now, what's really interesting in studies where patients have discontinued these medications, we see on average that there is weight regain. However, patients don't usually regain all of the weight that they've lost. And if you looked at the average patient, I think what's hard is that a clinical trial shows an average patient, the patient in front of you is not an average patient. They are a singular patient. And so if you took that average and then you looked at what is the waterfall distribution. So if you look at all the hundreds or thousands of patients that's in a clinical trial that discontinued a medication, what was actually each single data point? And you'll see that there are some patients who did maintain weight loss after discontinuing the medication. And then there's some patients that regained all of their weight plus some and sort of everything in between. So when we're thinking about it, I do want patients to be open to taking it for the long term. Again, they're the boss of their body. They get to decide at any point if they want to stop or trial decreasing the dose, for example. But as we're moving up in doses, we're thinking about, okay, how's your body doing? How's your body responding? We talked about that slow titration that I will often try to take with patients. And then as we're hitting weight goals, I've had some patients for whom we have to decrease the dose. You know, I've had patients for whom, even starting at a BMI, you know, I'm thinking of one patient, her weight is about 200, BMI in the upper 30s. She was pretty petite and lost weight. I was gonna say rapidly, but rapidly over the course of about a year and a half. Her weight came down to about 120 pounds. And we were really at a place where she was strong, her body was feeling great, everything metabolically had reversed. And then she was still losing weight. And it's like, and she didn't desire to, you know, she was expressing, oh no, I'm really getting too thin here. People are looking at me sideways. I don't want to weigh this. I, you know, I'd like to be in a slightly larger body, which, you know, she had to, it's hard to believe that you could even have those thoughts after living in a body that you felt for so long is larger than you desire it to be. But after a while, it's like, okay, we really need to step back on medication. So that happens sometimes where it's like, we just have to take a step back on medication. A lot of times in that situation, it meant decreasing the dose. But sometimes patients are hitting, they're at a really stable plateau at a goal weight. And we're deciding, hey, what would it mean to take your medication a little bit less frequently? You took it every 10 days or every 14 days, how would that feel in your body? If we did decrease to the previous dose of medication, how does that feel? And so rather than abruptly discontinuing a medication, we're just taking a slow step back and seeing, how is your body responding? What does that feel like? And I think there are a very small set subset of patients for whom short-term, and again, shorter term, you know, it's usually we're talking six to 18 months. And it's probably about five to 10% of people who may do well with that intermediate length dosing. Typically, that is people who have less significant obesity. So they have less excess weight on their body, as well as they've had less chronic metabolic disease. So, both in terms of when you look at things like A1C, do they have prediabetes? Do they have diabetes? If not, that's a better predictor factor of doing well on a shorter term dose. And or we're talking about weaken that happened relatively rapidly, you know, over the course of two to five years, people may also do well in shorter term. But generally, when we're thinking about chronic excess weight and more significant excess weight, we are thinking about long-term dosing. And most people, by the time they're on the medication, feeling the benefit of the medication, they really do desire to continue it. Sometimes there's challenges with insurance coverage. Again, probably another conversation for another day. The people do really like the way they feel generally on these medications, you know, desire to support them in a long-term fashion.

SPEAKER_00 27:40

Yes, beautiful. And you know, with uh these medications impacting so many other realms of uh disorders, like being studied for Alzheimer's, dementia. And of course, we have it for fatty liver disease or mash, metabolic dysfunction of the liver, uh, sleep apnea, and uh, you know, stu ongoing studies for rheumatoid arthritis and psoritic arthritis, so what the role played in inflammation. So we will have, I think, more specialists learning about these medications and in their own specific field or niche that the BFD approved. Uh, so there is a lot to learn about these medications, and I like the way you mentioned like structured what's the difference uh with short-term, long-term, and how do you tweak the doses? You know, one more thing I uh wanted to ask you, because I commonly have this in my practice, you know, because we use these medications even for type 2 diabetes, and both of these conditions tend to overlap, that's obesity and type 2 diabetes. Females who have PCOS along with these two Medicaid conditions and they're seeking fertility. And um, you know, either their fertility specialist and needs a specific A1C before they plan to conceive or undergoing a procedure, they are on GLP1 deceptor agonist for a shorter period because they're not safe during pregnancy or even before conception or before pregnancy. And they've had great success. It's just that we don't have the data or a clinical trial that, oh, you know, these patients benefited, achieved a specific goal, and were able to have successful pregnancy. But then what happens after pregnancy? Because, you know, pregnancy leads to weight gain with the baby. And that's what, you know, makes me curious. But many of these patients don't need GLP1 after they've delivered. Yes, they're they're breastfeeding, they're lactating at that time. But there is this improvement in hormone signaling, basically estrogen progesterone, and they're just less or more insulin sensitive because they are nursing and of course they end up being active. So many of them don't need the support of GLP1 receptor Agnes in the postpartum period. But again, the risk profile changes depending on what their lifestyle is, you know, a decade or five years down the road. So yeah, this always piques my interest as to, you know, what is happening in these individuals over a long time. And I feel clinicians will have a better answer because clinicians like you, you're seeing these patients. And then over a span of time or years, number of years, you can actually make your own conclusion because that's the real world. I also love the way you mentioned that the clinical trials, average patient versus the patients that you're seeing, or our clinician is taking care of these patients, you can't compare what's happening in a clinical trial versus the real world. So thank you for sharing all these amazing health bytes here on GLP1. I had one more question for you. We are surrounded with yes, uh, it's obesity, it's an epidemic, and how oppressive are the advancement of these medications at GLP1 receptor agonists. But say if someone has a contraindication, you know, I've had patients who've had medullary thyroid carcinoma, can't uh prescribe, and they've had steroid-induced obesity because they've been on steroids for their treatment. So how do you approach, especially being obesity medicine specialist, how do you approach care of such patients who have contraindications or cannot tolerate GLP1 receptor agonist? What is in your tool in your Pandora box for pharmaceutical management? Absolutely.

SPEAKER_01 31:06

And I think this is a really great question because we've had so much conversation, even just as a society, around GLP medications. And then the very small subset of patients who is unable to take them for medical reasons, feels really left out. Like, well, what about me? What is the option available for me? And I think I will point to one of my favorite studies that was done, I believe, in 2015. So before any of the weekly GLP medications were available. So we're looking at really the first generation obesity management medications. So medications like six senda, which is a daily GLP, medications like at the time, Belvik, which is no longer available, alorcasin, medications like Contrive, which is a combination of buproprian and naltrexone, and then medications like qsimia, which is a combination of fentramine and topiramate. And they put people into different categories looking at what was the reason that they struggled with obesity. And as we were talking about at the very beginning of our conversation today, people may have increased cravings for food, they may have increased, or they may have changes in appetite regulation, like they may have increased appetite, they may have decreased satiety, they may find that their body feels really low energy and feels like metabolically very slow. And so, based on questionnaires, they categorize people into different categories to say, okay, you're struggling with cravings or you're struggling with metabolic rate or you're struggling with appetite regulation, for example. And then based on that, they paired people with a very specific medication and they looked at the average weight loss at the end of the year. And the average weight loss in that trial was about 15% total body weight at the end of the trial. And while that doesn't sound that profound, when we compare that to the Wagovi studies, for example, the Zetbound studies, that's what we're seeing at the top dose of Wagovi. That's what we're seeing at Zetbound 5. And this is not with any sort of intensive lifestyle management. So again, that 15% being sort of just the average patient. And when we look at a clinic like yours or like mine or many other wonderful clinics out there where there is that intensive lifestyle management piece, we see patients who have really profound results. And so looking at that individual patient, you cannot take or tolerate a GLP and saying, okay, what is the reason that you're struggling? Do we think about the proprien andor niltrexone to manage cravings? Do we think about fentamine to help with metabolism? Do we think about topiramate to regulate appetite? Do we think about metformin, which wasn't studied in that trial, but does help with some of the underlying insulin resistance? And sometimes we can take different pieces and help build a plan to support someone beyond just the GLP medications. So this is all in your toolbox too for your patients. Absolutely. Or the patients who are like, I don't want to take the GLPs. You know, they're like, I don't want to take something trendy. I don't want to take something new. And I'm like, it's not that new. But, you know, there's other options. And I've had patients who, with some of these other medications, have done phenomenally. And so, and they're also cheap. They're very affordable, usually five to twenty dollars per month.

SPEAKER_00 34:08

Yeah. So this is where, you know, the expertise matters because, you know, now we have medical spas and GLP1 clinics where they barely have any physician there. And uh patients have just, you know, one set of information that if we have or we're struggling with obesity or metabolic dysfunction, this is the only medication that's available. But you know, the whole picture. And you're looking at the the lifestyle interventions as well as the entire pharmacological aspect, like what is going to be the right fit for you? I love that. Before we end, Dr. Sarah, so I'm gonna get back to our last rapid fire because the non-negotiable lifestyle habit, as per your recommendation, was the relationship with food. So if you can actually tell us, like, how do you implement this in your patient care and also for our audience and listeners before we close it? Because it has to end with some good hope and a very important lifestyle intervention, which hasn't been discussed as much on our podcast.

SPEAKER_01 35:08

Yeah, I think this, so many of my patients are very highly educated. You know, I've had patients who say, I could write a book on nutrition, and yet my day-to-day eating habits do not match what I know to be true. So when we think about our relationship with food, it's really powerful to examine what that looks like. I think practically a food log can be a great tool to be able to reflect back on what is actually happening. In my clinic, I have patients use a very simple food log where we're just writing down the time and what was consumed. I don't have them do any sort of weights or measurements, calories or macro counting. We keep it really pretty simple because we want it to be a very low barrier. If it takes them more than 30 seconds to log, they say you're putting too much detail in that. And then over time, we can layer on additional details there, like pay attention to what is our hunger, what is our satiety. So I have a quantitative scale that patients are trying to assess hunger and fullness. I will have patients log what was going on with their body, what was going on with their emotions. And so, really nice place to say, oh man, I had a really stressful day at work, or I'm on my period right now, or, you know, this, that, or the other. I'm having these types of side effects. I've had patients diagnose things like um celiac disease, actually, in one of my patients' migraines and finding migraine triggers based on their food log. But what becomes really powerful is we start to see these certain patterns of I really struggle because I'm running out the door on these days, or I struggle when I'm on vacation or when I'm out to dinner. And we start looking at are there certain common emotions that you're responding to? Are there certain situations that you're really having trouble navigating? And then workshopping those together to make a plan that feels very doable. And then over time we're practicing things may go really well and according to plan. But even those failures and big air quotes there, because a lot of times we have these setbacks that are amazing learning opportunities. And so we take time to evaluate, okay, you went on vacation, you gained five pounds. Let's talk about what happened. If you had a redo, how would you do it differently? And sometimes this can look like, and this is very controversial. I will have my patients eating dessert on their weight loss plan, for example, because I'm not interested in a short-term weight loss intervention. I'm interested in what is something that they can apply for the rest of their life. So if we're setting a goal, for example, of having two desserts per week, can they eat that and still be in line with their health goals? Now that will be a very specific thing. So I don't want anyone to, you know, take that and apply that to their own circumstance. But what's really true is that sometimes we're involved in these really restrictive diets where we feel like everything is off of the table and it can set us up for a restrict and binge cycle. And that is not doing you any sort of long-term favors or any sort of improvements in your metabolic health. So I really want us to work chronically on how do we fix that relationship with food, thinking of food as fuel of how we're nourishing and fueling our body. And with that relationship, then we get to put food into our body and make choices that, and sometimes it's even nourishing our soul. It's a very intentional choice rather than feeling guilty every single time we have a single bite of sugar, for example.

SPEAKER_00 38:24

That was uh yeah, just love it, love it, love it, love it. And uh very insightful. And you're leaving us, our audience, our listeners, with a lot of awareness also, which is so important, like one of our first steps, right? When we look at health. So thank you so much, Dr. Sarah. Before we end today's episode, please let us know where are your jewels hidden with uh GLP, Conquer Your Weight, and how can everyone access your podcast, YouTube channel, or your website?

SPEAKER_01 38:53

Yes, thank you so much for asking. So, my goal over the last couple of years here is to be a source of evidence-based and comprehensive weight loss for people who are looking for additional support. So, I do have a clinic in person in Charlottesville, Virginia. I see patients by telemedicine in Illinois, Tennessee, and Virginia. So for anyone who happens to be in those states, I'd love to support you as your physician. But for anyone who's outside of those states, I have a podcast called Conquer Your Weight. And just as of at least the day of this recording, it is also available on YouTube. So Conquer Your Weight is the name of it. You can find all of those too at Sarah StombaMD.com. I'm on Instagram and Facebook and TikTok and trying to be in all of the places to just get people the good answers that they need. As you mentioned at the beginning, I do also have the GLP guide, which is an online, on-demand video course for patients who are taking GLP medications and feel like they need a little bit of additional support. So maybe you are getting it maybe from your primary care physician who is happy to prescribe but doesn't have the availability to check in with you regularly. Maybe you're getting it somewhere online and you're like, gosh, I just I have questions. I'm not getting the support I need. The goal for that was to be able to answer some of those frequently asked questions that you might have and then to have it just when you need it. So there's lots of content on there. And I think the best part is that people who are taking that course, if you're reviewing it and you're like, oh shoot, I have a question that was not answered here, you can just email my team and we will get a video uploaded for you within a couple of days. And so I'm always updating that for people. And so it's been really fun to see that evolve as patients have taken it. At this time, it's$97 for one year of access. So it's just a steal. That price will go up eventually. So if you're thinking, or if anyone's thinking about buying it, I would definitely get it now. And all of that you can find at my website at www.sara stomba md.com.

SPEAKER_00 40:46

Sweet. Go people, get the right evidence-based science. Thank you so much, Dr. Sarah. This was like totally, totally insightful. And um I enjoyed the conversation and the discussion. Thank you. Thank you for having me. This is wonderful. Thanks for hanging out with me on hormones and hope. If you've loved this episode, do me a favor, hit subscribe, share it with someone you care about, and drop a review if you're feeling generous. Want more tools to support your hormones and health? Head over to unified endocrine care.com. We've got free guides, resources, and more waiting for you. Until next time, stay curious, stay kind to your body, and keep your hormones happy.