No-Zempic? No Thank You!

Episode 14 kicks off with a Kohlrabi recipe from Dr. Weiner and continues with tales of variable reactions to GLP-1 medications like Ozempic, the conundrum of weight regain post-VSG surgery, and the intricate dance of GLP-1 dosing. Join our circle as we converse on genetic factors influencing treatment efficacy, the alternatives for the non-responders, and the art of maintaining an injury-free fitness routine, and the all-too-common hidden sugars lurking in protein bars.

Facing obesity is an odyssey of both heartache and hope. Our guest, Chrisse opens up about her own struggles with obesity, the back injury that compounded it, and the undulating path of weight management post-bariatric surgery. She also talks about the emotional weight of obesity that often escapes the empathy afforded to other conditions. Together, we underscore the vital role of community and the unyielding spirit necessary to navigate these turbulent waters.

Brace yourself for life-altering insights as Zoe, our personal trainer and registered dietitian, bestows her wisdom on both nutrition and exercise, offering actionable advice to steer clear of injuries and elevate your fitness journey. As we marvel at the athletic longevity of the legendary Tom Brady, we also tackle the pressing issue of obesity medication access, dissecting the hurdles faced by patients and healthcare providers alike. This episode is a heartfelt symphony of health and wellness, aiming to change the narrative around the pursuit of a healthier life.

Transcript

Zoe: 0:17

Welcome back. Pound of Cure Weight Loss podcast, episode 14, no Zempik, no, thank you.

Dr. Weiner: 0:23

So, zoe, I made the most delicious thing for dinner last night. Tell me, trader Joe's has the Kohlrabi noodles, which is? You know? Kohlrabi is like this kind of solid, almost like a root green vegetable, super, super healthy, super nutrient, dense. They cut it into little slivers like a pasta replacement. We put that in the air fryer, just a tiny bit of olive oil, and then we put pesto on it Everything's better with pesto.

Dr. Weiner: 0:51

Everything's better with pesto, and pesto is pound of cure-ish. It's probably a little heavy on the olive oil for what we recommend for weight loss, but olive oil is one of those things that's maybe not the best for weight loss but is definitely not an unhealthy food. I mean, it's good for your heart and there's some. There's some health benefits from olive oil, yeah, moderations, yeah, but it can reduce your ability to lose weight a little bit. But it was so delicious so what was the texture like?

Zoe: 1:15

Was it crispy because it was in the air fryer, or was it more meat?

Dr. Weiner: 1:19

It was a little kind of yeah, it was more crispy, almost almost not quite like French fries, in that it wasn't kind of like that doughy, but it was a little kind of greener and fresher and it did have a little bit of crisp to it. Yeah, so the air fryer worked great for the Kohlrabi. You can steam it too. It comes right in the bag and you can steam it. But I feel like when I've done Kohlrabi in the past it gets like soupy and wet and my wife Trying to get the moisture sucked out of it.

Dr. Weiner: 1:46

Yeah my wife says she says over very frequently. She hates wet food, which I kind of get.

Zoe: 1:53

Yeah, that's fine, it's a new food descriptor.

Dr. Weiner: 1:56

Yeah, All right enough about our family dinners. What do we have on the show for today?

Zoe: 2:01

All right. On our show today we have what happens when you don't respond to Ozenbeck, our patient, chrissy, who I'm super excited to hear from her experience with weight regain after VSG and the cost effectiveness of her dosing strategy. So good stuff coming for that my nutrition segment, how to Avoid Injury During Exercise, and we're also going to be discussing that V-shaped weight loss curve after VSG, weight loss surgery success gene, and then also going to be talking about protein bars and sugar content.

Dr. Weiner: 2:33

Yes, I think we have a good show for you. Our first segment is in the news and this comes from the Atlantic. The first thing I want to do is give a plug to the author, yasmin Tyag. We actually this is a second episode that she's written that we featured. Our first one was an episode for a meat snack, where we talked about weight loss, surgery and medications together, and it really illustrated exactly what we do in our practice where we're combining the therapies.

Dr. Weiner: 3:02

But I find that her articles are number one, very scientifically accurate and really not prone to a lot of the judgment and bias that we see in most of the coverage on medications or bariatric surgery. And so this article is called Osempic, can Turn Into no Zempic, and it's absolutely worth a read, especially if you're on a GLP-1 medication and it didn't turn into that result that you expected. You're going to hear from Chrissy, our patient, and she's going to tell a fantastic story of how her body responded so positively to this medication. And there are definitely lots and lots of people out there, but it is not everyone With Osempic. If you look at the original trials, we saw a 15% average total body weight your 200 pounds, that's about 30 pounds, or 13.6% of people in the trial lost less than 5% of their body weight, and I think that's a really important thing about these medications just like with weight loss surgery, just like with weight loss for nutrition, there's variability. Some people lose more, some people lose less. Terzepatide we saw 21% total body weight loss and in the Surmount trial, 15% lost less than 5%. So, even though terzepatide is kind of a better drug than Osempic when it comes to weight loss, we actually saw the same, if actually a slightly higher, rate of poor weight loss response, and so that just shows you that there's a small group of patients about 14, 15% who really don't respond.

Dr. Weiner: 4:38

So why is that? There's a lot of different thoughts about that. I think the probably the most accurate one is you have to think about the physiology of these medications. So our body has receptors, and receptors are just proteins that we code from our DNA, and your GLP1 receptor and my GLP1 receptor are got to be a little different. Most likely, we have different genes and those proteins are going to kind of take a little slightly different shape.

Dr. Weiner: 5:07

Now keep in mind how these medications work. Normally, the actual GLP1 molecule binds to the receptor and it's released very quickly. That's why just giving someone GLP1 doesn't work, because it only lasts for a few minutes. The medications have a very long half life, and so they bind to the receptor. They stay bound to the receptor for a much longer time. It's a much greater affinity. Now, if we have different receptors, that drug may bind differently to your receptor than it does to mine, and so that difference, that almost like that lock in a key analogy where some people's receptors kind of bind tightly to the med and others don't.

Dr. Weiner: 5:48

Now what we don't know is if you don't respond to ozempic, do you respond to terzepotide? I personally think it's absolutely worth a try. I've had a lot of patients who've had not great response with one drug and then really responded well to the other drug. That's something to keep in mind as well is that it might be that your receptor works better with ozempic than it does with terzepotide. I think there's another piece of this, though, and that's patient tolerance.

Dr. Weiner: 6:18

We see two reasons why people don't respond or don't lose a lot of weight on these meds. The first is what I talked about it doesn't work. They take the med, they don't really have much response, they don't lose much weight. The second is they don't tolerate it. They take it. They have too many side effects, it's too unpleasant. They're like get me off this med, I don't want to take it.

Dr. Weiner: 6:36

That group. I think we can often still help them find success with some creative dosing strategies. If you follow the FDA or the drug recommendation for how to dose them, it's not going to work. You have to get creative in this group. But we have had a lot of patients who initially just didn't like the med at all, but by adjusting the dosing strategy and the diet as well, we were able to get them to tolerate it. I think this really puts us back at this idea that there's this treatment period. The base is nutrition and then we'll use GLP1 meds and weight loss surgery sits at the top and we use all of those therapies as we see fit to help people battle the disease of obesity.

Zoe: 7:20

I think it also just goes to show how individualized this is, just like with nutrition changes, just like with medication management. Having a team of support to help you navigate that individual case is really important, because we can help you identify maybe you don't respond to this one, but using a different medication or a different dosing strategy, like you were mentioning that we may be able to find a way.

Dr. Weiner: 7:48

You really need expertise at all levels of the pyramid. You need expertise in the nutrition that's where you come in. Expertise in the meds that's where me and Deidre and Bether or nurse practitioners come in and then expertise in the surgery. It's all three of those together that we find that we're able to help Really 95% of people successfully battle this disease, and I think that's amazing at no point in my career by seeing success like what we're seeing right now. Let's go to our patient story. This is our first, a remote patient. Everybody else has kind of joined us in the office. These patients are, you know, from out of state. They're joining us remote. I'm a little nervous about the technology, but let's see how it goes. So why don't you introduce Chrissy?

Zoe: 8:31

All right, let's hear from Chrissy. Super excited to have her on and Chrissy's been a patient for quite a while. Did you know her when you lived in Michigan?

Dr. Weiner: 8:40

I didn't actually. She kind of heard of me through the grapevine in Michigan and I may have met with her at one point, very briefly I think, way back when, and then she kind of tracked me down again and joined our nutrition program once we were here and set up in Arizona.

Zoe: 8:55

Okay, awesome, let's hear from Chrissy. All right, now we have our guest, chrissy. Welcome, so glad you're here with us.

Dr. Weiner: 9:02

Thanks for coming, chrissy, why don't you share your weight loss story with us? You're starting weight, you know and the things you've done to lose weight and where it's worked and where it hasn't.

Chrisse: 9:12

Sure, sure you know I struggled with weight even in my childhood. I was a kid who would hide food. That started really early, like six, seven years old. I would hide food, hoard food. My parents did not really know what I was doing. I remember even in my teenage years that my dad actually mentioned to me that he would see a ton of food wrappers even in the back of my car and things like that. So I really struggled with food and weight all through childhood.

Chrisse: 9:41

But I was also very, very active and I really thought that as active as I was, my body probably just was not responding Kind of an abnormal range of what you might see with a normal person. Even you know I was an avid swimmer and I remember, you know, looking at my body against other people's bodies and realizing I probably have an issue and kind of having that ingrained in me. And then you know, teenage into 20s and early 30s. It's really every single diet. It was weight watchers, it was Adkins which flowed naturally into keto. I did paleo for a really long time in adulthood and saw some results there, but really could not get out of the 200s with weight gain and my highest weight was just over 300 pounds. So it really became a very, very significant issue for me. And you couple that with a ton of inflammatory response and I was just in a lot of trouble and it was very long lasting and very broad reaching. It took me to some bad places, health-wise for sure.

Dr. Weiner: 10:52

You ultimately decided to have weight loss surgery.

Chrisse: 10:55

I did so, a friend of mine actually. I heard a rumor that she might have had weight loss surgery and her results were just incredible. So I just called her and I said, hey, you know, you know my situation. Would you be honest with me? Did this happen? Because if it happened, I have about 300 questions for you. And she was honest and she was so giving with her time and it really helped me get over any kind of hump I might have had or any kind of concern I might have had.

Chrisse: 11:27

I just had a laundry list of things I really wanted to cure for myself. I had a wish list for myself and I keep it in my phone because I really consider what has happened for me as a massive gift. But you know, when you look at a list like I really would like to wear short hair or wear my hair up on a ponytail where you can see my whole face. I want to be able to use something as simple as I want to be able to put my pants on without feeling like I'm going to pass out. I want to be able to tie my shoes without getting the pounding pressure in my face you know it's. I want to be able to ride a bike, these very simple things that you know. Your humanity starts to get strict away in some ways at higher weights, and there's there's no judgment about that. I've lived through that myself. But it does not come without emotional repercussion, for sure.

Dr. Weiner: 12:19

Yeah, I think everything you've said, all the limitations you've had about the putting on your your pants and you're riding your bike, they really, as I was listening to them, those are symptoms. You know, those are symptoms you're experiencing as a result of a disease, and the way you just described that to me was just, it was almost like clinical in a way, and that if you were talking about heart failure or having had a stroke God forbid or some other medical condition and the way that it limited your daily life, we would all be like, oh, you know, oh, that's so, we're so sad for you and that's, it's so. It must be so hard for you with obesity. You have all those symptoms, you have all those restrictions, but the empathy often is is fleeting.

Chrisse: 13:01

Oh, it's not often fleeting, it's just coupled with massive judgment. Right, you know, I I am not a doctor, obviously, but I have lived in this for my whole life and I have really researched, I I tried incredibly hard for so many years. I believe that there might be two different pools of obesity. I really believe that there is medical obesity, where you you need intervention to get that help, and there's probably also habitual obesity. I mean, we, you know, you go to college, eat too much pizza, you come over home over the summer, you get really active again and that goes away. So I think that there really are kind of two pools or potentially more. I just knew that I needed some medical help. I also I had a significant back injury and a failed back surgery which led me to even more problems, and I'm certain that some of that inflammatory response really played in to me developing back issues and then having a very long run of trying to get through that.

Dr. Weiner: 14:54

Injury is one of the most common causes of weight gain. It's a weight gain and that's something yeah, that's something we kind of, and a lot of times I've heard this story many times is they were told to exercise very vigorously, well beyond what their physical capacity was, and they got injured as a result of that. And, of course, when you get injured, you gain more weight.

Chrisse: 15:17

It's funny that you say that one of the first times that my back injury surfaced I was actually on a pulling machine in a gym with a trainer who was not educated enough to be training maybe anyone, but certainly someone at my weight with my issues, without really understanding it. And that was really the first time that that lower back really kicked in for me and, honestly, even after weight loss surgery that's really it emerged again because I think the damage was already done and then I had some regain. Even after weight loss surgery that occurred after that. You know, during my weight loss surgery I really leaned into my sleeve. I am one of those people that I, you know, when I felt that restriction, I was celebrating it and I've, you know, I study a lot. I still stay on all of the boards, I stay really active in support groups and I do see people react after surgery. It's almost a shock that you can't eat and people say you know, I just I don't even want to cook because I can only eat a few bites, and I was one of the people saying I can only eat a few bites. You know they'll almost celebrate like that.

Chrisse: 16:24

But at that high weight of of it was 300.4 was my high weight and my surgery weight in 2017 was 277. And I ended up losing down to like my stabilized loss was right around 143, 144. Wow, and then I had a significant back injury that led into a very long run of major steroids, a ton of different meds, you know, steroids making you crave food, crave carbs, all the inflammation that comes back. And from that 144 point, I find myself back at 199. I remember clinging to that like 199.9. Don't cross back over. Stay in Wonderland, stay in Wonderland. But that was a really, really difficult to get back there Emotionally and just wondering how I was going to kind of land on the right side of my surgery again.

Dr. Weiner: 17:21

Yeah, how soon was that after your surgery that you injured your back and had to take the steroids?

Chrisse: 17:26

Yeah. So the injury, the real kind of the final straw of the injury, happened in late 19, early 2020. So it was, you know, a couple of years, two years and a couple of months, and I again, I'd been stable for a while but it really threw me almost immediately after those meds started, you know, and I, very thankfully, after a number of months, was able to find a surgeon who could help me. So the back injury was cured but I could not get my weight back on track. I almost re-stabilized, but at you know, almost 200 pounds.

Chrisse: 18:03

And I was with you guys. I joined the support groups, I was going to nutrition classes, I was coming in, I loved the support there. But I remember there was one day, dr Weiner, that it was one of your groups that you joined and you were just asking people in the group, like what's your story, what's happening? And you asked me specifically, like tell me, tell me what's going on. And I let you know those details. And you said, listen, you have got to get this weight back off and you have to do it now because your set point is going to set in at that weight and your struggle is going to multiply to get back down and it was at that point really where you mentioned Wagovie to me and I was super excited to hear that there might be a possibility for me.

Dr. Weiner: 18:49

So you started Wagovie and I thought this was actually kind of a classic scenario where these meds are appropriate, because it was, you know, to some degree, I think, like you got to fight fire with fire and you gain weight from medications, and so if we use a medication to help with weight loss, sometimes that does make some sense. And so we got you on Wagovie. I think you ended up getting it from a local provider, right, did you talk to your PCP about it?

Chrisse: 19:15

Yeah, I did. I went back to my primary care because it was new and my primary care has been with me for years and she was incredibly supportive of my weight loss surgery, had partnered with me following weight loss surgery, I really reached out. I really wanted a strong support system around me. I'm very lucky to have an incredibly supportive husband. I have doctors around me who have been supportive. And she actually was not familiar with Wagovie at the time and she said you know what, let me do a couple days of research and let's talk again in a couple days and I'll come back with a recommendation. And she came back and she said Chrissy, do it. She said everything in your history and this med they go together so well. I think you're going to be incredibly successful. Trust him and do it.

Chrisse: 20:00

And you know I did the normal ramp up on the Wagovie the 0.5 to the to the 1, to the 1.7 to the, you know, and so are the 0.25, I guess, starting dose. And within one hour of my first dose I knew my head was right again. It was so fast that day. I remember talking to Zoe I think it was like later that week and I said you would not believe it. But within hours my head was right. It took away every craving I was having I had. It was completely quiet again, like I was right after surgery. All of the food voices were gone, everything was quiet again and I.

Chrisse: 20:39

It was just such a sigh of relief and I had the normal kind of re-hungry that you get towards the end of those low doses. But I again I just really leaned into it. I stayed on track with the, with the ramp ups monthly, and just saw a ton of success with it. So during that time that I was on a normal dosing structure with Wagovie I I lost not only back down to my post-surgery weight of that 144 point but I actually now kind of stabilize between 131, 133 somewhere in there so lower, and that I've been very, very stable for a couple of years now at this level where I just you know that set point conversation you had with me really resonated and I feel like that is what we've achieved. It's this new set point where my body just kind of stays here and is super happy and as you know, I'm not on a normal dosing structure.

Dr. Weiner: 21:38

No, so. So what are you doing now with Wagovie? What, how much are you taking? How are you working it out? How are you getting it?

Chrisse: 21:46

So I actually am one of the people who has to do a cash pay. But you and I really worked through some strategy around. You know me saying, okay, the week comes up and I'm supposed to redo, but I'm really not hungry. And then I redo and I'm getting all of the negative side effects of it and I feel like I could go longer. And so it was like, well, can you get to two weeks? Okay, Well, can you get to three weeks?

Chrisse: 22:14

And I remember the conversation that you and I had where you said, Chrissy, dose when you get hungry, when that, when that kind of inner dialogue starts again, not real hunger but head hunger, when that head hunger kicks back in dose. And now I really can go between three and a half and four weeks very easily. I mean, this last run was four weeks and three days in between dosing. I am at the highest dose right now, but post holidays I needed just a little bit of a bump. But even this last round, when I went the four weeks and three days and then dosed again, I can tell that it's too high again and I need to drop back down to the 1.7. So I've been very, very successful at stretching the doses you really lean into the nutrition and you stay on a plan. You don't stretch how much you're eating. It really helps to stretch the days in between dosing. I've been super successful that way.

Dr. Weiner: 23:10

Yeah, I think it minimizes the side effects and that also what you said is. It really emphasizes nutrition. You can't pull that off if you're not putting in the hard work on the nutrition side. I think you I know you you and Zoe have worked a lot on that. I think I would put as a disclaimer that you certainly have an alternate dosing strategy, but this is something you and I came up with together.

Dr. Weiner: 23:34

This is not something you kind of picked up at some compounding pharmacy and started trying to work through it on your own. I think that's really the key is you got to work with your prescriber to come up with something that works for you but is also within the confines of what's medically safe, because I you know we do. I do get some questions sometimes from people and say, hey, I came up with this idea and I'm like no, don't do that, you'll be sick for a week if you do that, and so you have to be very careful with this. You kind of slowly or organically came up, come up with this approach and this is what works for Chrissy. This is not necessarily a standard approach for everybody, and that's what I'm finding is that we have to, just like with nutrition work for individualized nutritional plans for people based on their lifestyle and other limiting factors.

Dr. Weiner: 24:22

We have to come up with dosing strategies for people as well.

Chrisse: 24:24

But, dr Weiner, this is why you and your team are changing people's lives. You know there is such a trend in the industry for surgeons to kind of herd people in. You get the surgery and you leave. There's no real support. People have very basic questions following surgery that always surprise me that they're asking because we are lacking in support in this field in such a big way. And I know I tell you every time I see you.

Chrisse: 24:56

But the work you are doing, it's changing people's lives. It's giving people a life who haven't really had a life. It's not that I wasn't living, but dealing with the emotional side effects of obesity every minute of every day, and that is not an understatement. It severely impairs you as a human and I cannot thank you and your team enough for the work you're doing. The partnership that you offer, the consistent support, the creative ways that you are supporting, is making a huge difference in my life. I know it is doing that for other people. I encourage anyone I come across who has questions please go watch the videos, please join the groups. It is life changing. It has been for me and I am so grateful to you and your team.

Dr. Weiner: 25:43

Thank you. We're grateful for you. We are very grateful for you. I think that's a great little plug to join the nutrition program, don't you think? So if you're out there and you want to join our nutrition program, it's open for everybody. I have support groups. Zoe has support groups, Our peer leaders have support groups. We're seeing. We are so grateful that you came on the show and shared your story. I think it's fantastic. We're so happy for you to see how much you've transformed your life with your surgery, the medications and really your deep commitment to nutrition and lifestyle changes. So we're happy to see you on this path and really see a lot of good things for you in the future.

Chrisse: 26:20

Thank you for giving me my life back. Thank you, thank you, thank you.

Dr. Weiner: 26:25

You know her story of her back injury after her surgery, which resulted in steroid use in a lot of her weight gain. A lot of people kind of look at that as something that is inevitable or just an unfortunate event that happened, but I'm not sure I view it that way. Zoe, you're a personal trainer as well as being a registered dietitian. Talk to us a little bit about what you can do to avoid injury during exercise.

Zoe: 26:47

Absolutely Well.

Zoe: 26:49

I have a couple of thoughts, but I have three main points that I think I'll try to keep a concise here.

Zoe: 26:54

So the first one being is to, if you are new, you don't want to go from exercising zero days a week to being in the gym six days a week, right, You're not going to go from zero to 100 that fast and so really knowing meeting yourself where you're at and going slowly increasing.

Zoe: 27:14

But a big recommendation would be to utilize those kind of introductory free, personal training sessions that a lot of gyms have, not necessarily to get a really intense training session out of, but to say, hey, can you orient me to the equipment so that you learn how to use the equipment and the weights safely, and that sort of thing, so you know what you're doing and then that way you can start slow and build up right. Another thing is working on your flexibility and you're doing some active warm-ups beforehand, stretching afterwards, those sorts of things to really make sure that your joints and your muscles are nice and warmed up so that you're not, you know, making yourself pro-dentry. And then the last one actually has to do with nutrition. So I know so many people who exercise in the fasted state because they think or they've heard that it burns were fat right, and I actually wrote a paper in college on this. I did a research like a.

Dr. Weiner: 28:17

Research study.

Zoe: 28:18

Review of the research, there's not enough significant data to show that, but what training or working out fasted can do is make you feel more tired, make you lower energy and make you more prone to injury. If you are dragging yourself through the workout and your form is getting sloppy because you haven't fueled enough properly beforehand, then that's going to make you more prone to injury as well.

Dr. Weiner: 28:46

Yeah, the flexibility thing kind of to me. I'm a Michigan guy, obviously huge Tom Brady fan was quarterback at Inrus in Michigan back when I was at medical school there. So he had a 20-plus year career in the NFL. I mean the NFL quarterback that's like the most injury prone job there is. He didn't do a ton of weightlifting, he focused primarily on flexibility. That was like the biggest part of his training was flexibility becoming more resilient. He thought that that's what made him most resistant to injury.

Zoe: 29:19

Wow, that's really fascinating, Like if you get sacked and your legs go over your head and you're bouncing up in the splits. I mean that's a good thing yeah.

Dr. Weiner: 29:28

I mean I looked at that and I'm a few years older than him, but not that many years older than him and for the longest time. I'm like if I tripped and fell from walking it would really mess me up. And this guy's out there being chased to 300-pound 20-year-olds totally and taking hits. I mean it was really remarkable. But those are great points and I think the most important thing is that injury causes waking and if you exercise and become injured, it's actually bad that you even chose to exercise. You'd be better off if you didn't exercise. And that doesn't mean you don't exercise. It means make sure when you're exercising that you're taking all the steps that Zoe recommended to prevent injury, because that would be very damaging, and we heard from Chrissy just how much that can hurt. All right, so let's move on to the economics of obesity. So this topic I want to talk about is where is all the we Gove? And we had one of the we Gove reps come in right shortly I think it was early 2023, and they said listen, it's only going to be a few more months and then this backorder stuff is going to be old. We're now a year later and we've seen absolutely no let out.

Dr. Weiner: 30:46

I think the first thing is to recognize that there is a remarkable demand, so lots and lots of people want it, but it has been on backorder for over a year. There are almost none of the lowest three doses. So the way they've restricted this is they've taken those entry doses the 0.25 milligram, the 0.5, and the 1 milligram and they've restricted manufacturing of it so that only people who are already on the higher doses can get the medication. There was a quote and I really related to this quote in an article I read recently and it's actually from Michigan Medicine and it's from Dr Andrew Craftson, who's a clinical associate professor in the Division of Metabolism and Endocrinology and Diabetes, and he said it's created this living hell. And I think Sierra, our office manager, can share that thought that patients are incredibly frustrated with their inability to get it. We can write the scripts, we finally get it prior off and then people are running all over town trying to get this medication. But Novo Nordisk, which is the manufacturer of WeGoBee, has invested $11 billion, which is probably about two months of profit for them, into the investment in manufacturing. They doubled the availability of manufacturing these lower doses. They so far they've served one million patients. So there's one million people in the US since 2021, when it was released, who've been able to get the medication.

Dr. Weiner: 32:14

The PBMs the pharmacy benefit managers, who I've talked about in the past, who are generally this unscrupulous group that profits extraordinarily over high drug costs. They have set lower reimbursements for the pharmacies, and that's discouraged a lot of the pharmacies from carrying these medications, and so that's creating a lot of push and pull as well. So when we place all of these constraints on the pricing of the medication and make it overly complex, we generally get things like shortages and a lot of the problems that we're facing right now. Even with this shortage, the drugs are incredibly profitable for Novonordus. The GLP-1 medications, which is primarily going to be Osempic and WeGoBee for them accounted for 61% of Novo's $7.9 billion in revenue in the last quarter.

Dr. Weiner: 33:07

So I think the question that's on everybody's mind is well, what about Osempic and compounded synaglutide? So if you can't get WeGoBee, this is essentially the same drug. Osempic has become almost impossible to get if you're not diabetic. All of the loopholes we've been using over the years to get patients approved for these medications those have been shut down. If you have diabetes and your medical policy and your diabetes fits what your medical policy criteria are, we can get you Osempic If it does it. You can't get Osempic unless you can self-pay for it.

Dr. Weiner: 33:36

The compounded synaglutide we've talked about this in the past. We don't recommend or prescribe compounded medications. We think that it's very unclear whether they're safe or not. Pretty much every single medical organization that knows anything about prescribing in the pharmacy supply chain has recommended against the use of compounded drugs. We do also think that these are going to disappear as Novo Nordisk and Eli will begin to go after and defend their patent, which, quite frankly, they have a legal right to do. So we're hopeful that sometime in 2024, we're going to start to see more WeGoBee and have more patients get access to it, and this increase manufacturing comes through. Then I think we should. So there's good news on the horizon for access to WeGoBee.

Zoe: 34:21

All right. So let's go ahead and hear from our followers, the listeners, the patients who are submitting questions. I actually had somebody who, in one of my nutrition sessions the other day, who said you and you've answered two of my questions so far on the podcast. I mean, that's great, Keep submitting them. So if you submit a question, maybe we'll be able to get to it. So, Sierra, what do we've got today? Okay?

Sierra: 34:46

First question Hello, loving the new podcast. Long time pound of cure follower. I'm a 37 year old male. Starting weight was 300 pounds. I had a VSG in October of 2022 at 280 pounds. My lowest weight post-surgery was 200 pounds and I am currently 220 pounds. I consider my surgery a great success. Over the past six months I've been consistently gaining weight two pounds per month. I haven't really had a stable post-surgery weight. I'm staying very active about three days a week, weightlifting, two days a week utilizing some type of fun cardio. I am probably 80% adherent to the metabolic reset diet. I would like to see my weight stabilized below 200 pounds. What is the best course of action? Improve diet adherence, investigate GLP ones, change my exercise routine. What do you recommend?

Dr. Weiner: 35:35

Let's talk about what you'd recommend from a nutrition and exercise front.

Zoe: 35:41

It sounds like he's got a great routine of weight training, maybe defending on how many. Just that neat that you've talked about before the non-exercise activity thermogenesis If you're sitting down all day, perhaps there's the area of opportunity to get up and go for a little bit more walks and that sort of thing. But we don't know that because, see, we haven't gotten that information. 80% adherent to the metabolic reset diet goes into that 80, 20 rule that I think I've talked about before on the podcast. Obviously, without digging into his day-to-day nutrition. Everybody has room for improvement, sure. However, it sounds like he's been doing a pretty dang good job.

Dr. Weiner: 36:22

I think 80% is pretty good the idea that you have to be 100% compliant and going from 80% to 100% you're going to get a little bit of results. But I don't know that you're going to change this course. It might go, instead of two pounds a month, it might go to one and a half pounds a month, something along those lines. I think we're seeing something that we just unfortunately see way too often. I'm grateful, at least, that I'm seeing more and more patients coming in who understand that weight we gain after sleep is very common.

Dr. Weiner: 37:01

We've kind of Made it like this taboo topic, like you can't ever say, oh, my bariatric surgery didn't work the way I wanted, because you've gone through this you know incredible thing you've given up a part of your stomach with a sleeve, had a major abdominal surgery and it didn't quite work out the way you want it.

Dr. Weiner: 37:19

And so I think that it's important to recognize that with a sleeve, the meds for most people are part of the equation, and you know we heard from Chrissy about her story and how much, how much adding the meds added, how it brought back the function of the sleeve, that kind of there's that set point Membrane, almost where it was like oh, you had a sleeve, let me help you back to where you were and and I just think that's part of the deal with sleeves for most people, unfortunately knowing that going in is important and I have that conversation with every prospective bariatric surgery patient now and say, if you want to sleeve, let's also talk about the meds, because it's probably going to be part of the plan and I think it's important for us to embrace that because it's the scientific reality.

Dr. Weiner: 38:09

It's not that somehow sleeve patients are less compliant than bypass patients. It's that a bypass has less weight regain and we have to accept that and educate people so that you can make the best decision for yourself Going into it. I think you know this. This person should be exploring the medications. Yeah, I thought you were gonna say that.

Zoe: 38:27

Yeah, I didn't want to say it, cuz I'm not the doctor, but but at this point you've heard me say yeah like. It sounds like a perfect opportunity for the GLP one.

Dr. Weiner: 38:37

It's cuz. That's what works. Yeah, you know, that's what we're seeing it again and again over and over. Yeah, All right. So what do we have next?

Sierra: 38:45

Okay, next Question. Hello, I will be having gastric bypass in a couple of months. I've heard you mentioned in older videos that a gene has been identified which determines how much weight you will lose with the surgery. At the time you made the videos, maybe six years ago, you said that a commercial test for the gene was not available at that time. Is there one available now? I would really like to know if I am genetically programmed to lose less weight average weight or if I will be a super loser.

Dr. Weiner: 39:13

Yeah, super loser in the bariatric space is a good thing. I think other terms that might not be the most friendly they can call somebody. So the answer is no, there's been absolutely zero progress on this, unfortunately. My suspicion is that it's because it's not one gene but many and I think we're seeing this with with as the as we do more and more research that there's definitely a familial component. We I see this over and over again. If you, if I see a sibling or a child or a parent of one of my Successful patients, I have a hunch that this person's also going to be successful. I'll often cater my procedure recommendations based on family members, success or lack of success with different procedures and so. But we still don't have that and in all honesty, I think this line of discussion has kind of Decreased. It would be great if we could make predictions for people about it. You can use on our website. We do have an outcomes predictor tool.

Dr. Weiner: 40:11

I think that bell curve is a little tighter for a gastric bypass, meaning we we'd see patients kind of fallen Within a smaller range of weights. After surgery with a sleeve we see a little wider range, but now with the meds, the sleeve, maybe we may be seeing that tighten up a little bit. So I think you know life is filled with uncertainty and I don't you know. But having weight loss surgery there is some risk involved with the procedure. There's some risk involved in that you're not gonna reach the level of success that you might hope for, but in general the odds are very much in your favor proceeding with either these surgeries, whether you proceed with a gastric bypass or a sleeve with the intent of combining it with the medications. I think now with the GLP one meds we're seeing much more frequent success and we're seeing Less problems with the way we gain because it's treatable.

Sierra: 41:03

Okay, final question here from Nick. This is from our website how do you get high amounts of protein without protein shakes and bars? I buy bars and shakes that have zero to one gram of sugar. Are these still acceptable?

Zoe: 41:17

So I mean zero to one grams of sugar. Yeah, that's great, but we know that protein bars are obviously Super processed, so there are going to be a lot of artificial sweeteners, a lot of Huge ingredients list, right, and so in a pinch is there. You know, can you keep a protein bar in the car or in your backpack or whatever. Yes, I would recommend the RX bars. Have you ever had those? No, the reason why I like that is because the ingredients list is super short. It's just peanut, egg whites, date and it's it's all whole food. Oh, that's great. So it's really great. You know it's a little chewy, but that's great, you get. You get a little workout, a little mouth workout in.

Zoe: 41:59

So you know, obviously our goal is to be reaching your protein goals through as much whole, real, unprocessed food as possible. If you're struggling, volume wise, to get that protein in, then maybe trying more small, frequent throughout the day, like I could like to call them mini meals with protein in there. Having smoothie is a great way to add a bunch of protein. But ultimately, yeah, zero to one grams of sugar, that's great, but think about all those other processed ingredients in there. Maybe check out the RX bars and try to get as much of your protein in through Whole Foods as possible. Try to be. You know you have to be your own self-advocate. You have to be your own nutrition detective. Read that ingredients list, read the nutrition facts label and if you need help and support doing so, then definitely come and join our nutrition program and I'm happy to help.

Dr. Weiner: 42:46

Yeah, I other great shows. Oh wait, fantastic, we'll see everybody next time.