Listener Q&A: Does It Make Sense to Titrate Up When You’re Seeing Results?

Since introducing our new fan mail feature, we've had some fantastic questions rolling in, and this week, we're tackling a common concern: Should you increase your dosage of anti-obesity medication, even if it seems to be effective?

Join me as I delve into this listener’s question and explore the complexities of titrating up. While it might appear logical to boost your dosage for better results—especially when you're experiencing weight loss and improved health markers—there are important considerations to keep in mind.

In this episode, we’ll discuss the delicate balance between medication dosage and your nutritional needs, the risks associated with increasing medication too much, and how insurance companies can influence these decisions.


References

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Audio Stamps

00:30 - Dr. Rentea discusses the challenges and rewards of attending two back-to-back conferences, highlighting the value of in-person connections.

03:03 - Dr. Rentea addressed a listener's question about increasing the dosage of an effective anti-obesity medication, emphasizing the complexities of weight management.

06:23 - We learn how insurance companies often force patients to increase their anti-obesity medication dosage despite its effectiveness, revealing a gap between clinical practice and insurance policies.

08:40 - For questions that are too detailed for the podcast, Dr. Rentea suggests scheduling a consultation for personalized guidance on general medical topics.


Quotes

“If someone already is having great fat loss percentages, they're not having urges and cravings, they're able to get all the healthy food, they feel like they're in a great flow, why would we go up on the dose?” - Dr. Rentea

“You're shamed if you go up, you're shamed if you don't. And ultimately, my answer is how about we just focus on what the data is doing. How are you feeling? What are the symptoms looking like?” - Dr. Rentea

“If you're doing really great and you go up too much, you actually start under-eating. You start not losing as much.” - Dr. Rentea

“There's this fine line between being in a calorie deficit and getting the food that you need versus being so suppressed, you don't even want to get the fiber in anymore.” - Dr. Rentea

All of the information on this podcast is for general informational purposes only. Please talk to your physician and medical team about what is right for you. No medical advice is being on this podcast.

If you live in Indiana or Illinois and want to work with doctor Matthea Rentea, you can find out more on www.RenteaClinic.com

Transcript

0:28

Welcome back to another episode of the podcast. How are you all feeling today? It's another Monday. I have to say I am on the tail end right now of two conferences in September, which we will not do this again. In one way it's absolutely amazing going to these things. I find it incredibly hard having a less than two week turnaround between these things. The reason being the rest of your weeks really get compressed. And so I just, I'm going to think through my next year differently, but I've had. I've actually gotten to meet a coaching client that I had a long time ago where we've kept in touch and it's incredibly powerful to get to meet with people that you really respect, that you just like who they are and you get to spend some time with them. You get to eat a dinner, you get to connect with people. There's this term that my coach uses and it's called collisions. When you're in person, the quality can often be different. So I find that It's incredibly difficult to get to these conferences, whether it be that you're having to pay for airfare or physically taking the time off of work, just all the logistics involved. But the quality of being there a few days and being in the presence of people, and even if it's a one hour conversation, I want to give you an example. Two weeks ago, I I was at the Allie Nowitzki conference. This was in the Berkshires. I never know. Is it Berkshires or Berkshires? Maybe neither. Who knows? But anyway, so it was about a one hour car ride from where the airport was to where the resort was. And so we get picked up and it's me and one other person from this program because we had come a day early. And people were coming at different times. And I had the best conversation ever with her. Lisa, if you're listening, I absolutely, she knows I'm such a fan of her and she's a psychiatrist. It was the best conversation ever on so many levels. And you know what I said to her? I turned to her in the car and I said, I'm really glad that we got this hour together because I know that the whole rest of this conference, we're not going to get this again. And I don't think she believed me. And then when, We were leaving, she texts and she said, I know what you mean. Because I know at these conferences there's just so much happening between the talks and the meals and all the things that If you get one chance to connect with someone, it's amazing. So I try to not squander that, you know, if I'm walking, getting a coffee, I try to say, hi, you know, have a quick conversation because you just don't know if you're going to get to connect with that person again. So I'm super grateful for this time. I'm also very grateful to be home for a few months. I think my next trip is in January and. I'm grateful for that. I, I'm happy to meet people, but then I'm really ultimately a homebody. So one of the things that has been super, super fun is that a few months ago, we unlocked this fan mail feature, which makes it really easy for you to ask us questions on the podcast. Now again, I really want to remind you if you're going to use that, if you want to hear back from us, you've got to put your email or some way for us to contact you. Otherwise it's anonymous, which tends to be great, right? I mean, you want it to be anonymous when you When you're writing to us, but, if there's sometimes you can tell if that person wants to hear back and I'm like, I have no, there's no reply that just doesn't exist on this feature. Today we're going to do a Q& A and this is really going to be about do you titrate up or not on the dose of an anti obesity medication if it's already working for you or vice versa. So here's the question. I'm on day 14 of ZepBound, down 5. 8 pounds and one inch waist circumference. No side effects. Prescribed five milligrams at week five. But if it's effective at this dose, why increase? Answer I received from my nurse practitioner was that it is a manufacturer's recommendation, but I need a better explanation. Thanks. Okay, so this is a really great question. So this is where we get into what's called the art of medicine, right? So a lot of people, when they look at a medication, they're just looking at what's the prescribing recommendations, and sometimes it makes sense, okay? So let me give you an example. If, a lot of the times with antibiotics, we will have certain regimens and certain lengths because we know that that organism does not die if you don't complete the treatment. But for something like weight management, there's a little bit more nuance involved. Now, I will say this is a very rapidly evolving thing because Over the past few years, our understanding of this has greatly increased because literally it was 2022. We're not many years away from that, right? It's a few years when we had some of these newer medications like the Zep Bound that you're talking about. That's Menjaro, if you're thinking the other name. That's Trezepatide. Okay, same thing. So initially, everybody, every single month was going up because that's what they had done in the trials. But then what we noticed over time, if you have someone that's really practicing a lot of obesity medicine, we noticed, if someone already is having great fat loss percentages. So remember, we don't want to go over 1 percent per week, 4 percent in the month. But even if it's 2, 3%, but they're feeling great, things are rocking and rolling along. If they're still feeling suppression, if they're not having urges and cravings, they're able to get all the healthy food, they feel like they're in a great flow, why would we go up on the dose? That's my personal perspective. Again, nothing on here is medical advice. You're going to talk to your medical team, but that is just, one perspective, where I realize personally working with patients, there are some where they need the dose increase. They're still really hungry. They're not noticing results. Things are not clicking for them. There's no shame in that either. By the way, a registered dietitian made a great video how she, she always sees that there's always this polarization happening in this community where you're shamed if you go up, you're shamed if you don't. And ultimately, my answer is how about we just focused on what's the data doing? How are you feeling? What are the symptoms looking like? We weigh all of these factors to make a decision. So is this nurse practitioner wrong? No. Is the other perspective wrong? If you would not go up because you're already having success and why would you go up? That's not wrong either. So the real question is, do you like your team and the direction in which they're taking you? And all that I'm hearing here, when that nurse practitioner answered it in that way, that this is the manufacturer's recommendation, it's not wrong, but it tells me that they have no nuance involved. It also, I'll tell you another thing, they might also know, which is also true, again, also true. And all of this is true. Many insurance companies in the U. S. will not cover more than two, some of them only one month at the same dose without having to go up. I have a patient that's doing phenomenal and they're forcing her monthly to go up. And it's ridiculous, right? It's ridiculous that someone can be doing amazing and an insurance company that has absolutely no medical knowledge and they'll say, we're using this study. Yes, there's a study, but then there's also the clinical practice where there's the reality, the side effects, the responsiveness of people. So anyway, long story short, you don't have to go up. Many people will do great not going up for longer periods of time, but that was how the studies were done. A lot of insurance companies force it. A lot of people that are not as skilled in writing these medications because they're just not doing it as often. I mean, it's so interesting. Some of these things I think to myself, oh my gosh, this is so obvious. But no, that's all I do all day long, right? I'm also used to the, the having to fight insurance and a lot of clinics, they don't enjoy that. In fact, what's on my list for later today, it's called an insurance company that hasn't been answering us in the past week. And this person, this is a continuation medication. This is not something we can sit around for 30 days in the beginning of writing a medication to figure out if they'll cover it or not. So, all of this to say to answer this, sounds like you've been doing amazing. I would almost be curious the feedback here that when you were doing that great with going up, if you suddenly then were too suppressed and cause sometimes what I actually see is that it backfires. If you're doing really great and you go up too much, you actually start under eating. You actually start not losing as much. It's like there's this fine line between being in a calorie deficit. And getting the food that you need versus being so suppressed, you don't even want to get the fiber in anymore, meaning the vegetables, the fruits, the nuts and seeds, the things that will support you, you don't even want to get them in anymore. You can hardly handle a cracker or two. That's not the answer. That's not the answer long term here. And so, I hope that this answered your question. Keep these questions coming. Know that I wish I could get back to all of you. I can't. Some of you, if you put an email, some of you have had such, if there's a podcast that we can point you to, my team will point that out. And you know, you're grateful to know, oh, you've already covered this. We can get that to you. The one caveat I want to say is that, Some of you are writing in questions that are so long and detailed. Honestly, that's a consult. So I do have an option if that's something you're interested in where you're not my patient, but we talk about, for example, some of you have had questions about carbohydrate intake, you know, things like that. That's really general medical information that. It's really sort of in a health coaching capacity. I can do that for you. We have links to schedule that whether it's a 30 minute consult or a full hour. So we'll make sure to put those links in the show notes here if that's interesting to you. But I really try to help as much as I can in a, in a sort of free goodwill capacity. But then at some point there's just, you know, Too many variables where I wouldn't be able to answer it. All right, final plug here that if you're wanting to do that upcoming January 3030 program, we're going to have the link in the show notes below. We're going to register very, very soon for that. So make sure that you are on the list for that if you want to do that. I hope this was helpful and have a great rest of the week.