Hot Diggity Dog - Costco’s New Weight Loss Program

 Episode 22 of The Pound of Cure Weight Loss podcast is titled, Hot Diggity Dog - Costco’s New Weight Loss Program. The name comes from our In the News segment where we talk about how Costco is entering the medical weight loss space. We dive into what this means for GLP-1 access and whether or not patients benefit. 
 
 In our Patient Story segment, we talk to Suzanne who gained weight later in life after an early and then late pregnancy. She had some moderate success losing weight on her own but ended up hitting a stall that she couldn’t overcome so she reached out to us for help. 
 
 Zoe shares a strategy on how to incorporate new habits in our Nutrition segment. And Dr. Weiner begins a two-part series on drug patents in our Economics of Obesity segment. Part 1 focuses on how drug patents work and how the system can be manipulated to favor the pharmaceutical companies over patient care. Part 2 will air next week. 
 
 We also answer 3 listener submitted questions including, homemade pizza made with cauliflower crust, veggies, and vegan cheese, our thoughts on Contrave, and diagnostic pattern dumping after surgery. 

Finally, some exciting news this week! We have added a new Weight Regain program to the practice. This program incorporates the expertise of both myself and Zoe and utilizes nutrition, GLP-1 medication, and behavior modification to help you lose the regain and keep it off. Plus! It’s available to anyone in the country.
 

Transcript

Zoe: 0:17

All right, welcome back to the Pound of Cure Weight Loss podcast, episode 22. Part two yeah, so we actually had to rerecord this because our audio was not where it needed to be, so we wanted you to have a nice crisp, clear audio recording.

Dr. Weiner: 0:36

So First time in 22 episodes that we really screwed this up, so I think that's pretty good.

Suzanne: 0:41

Yeah.

Dr. Weiner: 0:42

I know it sounds really professional out there, but we are. I'm not going to lie. We're a little bit of an amateur shop here with our podcast. But anyway, let's talk about the title of the show. Oh yeah.

Zoe: 0:54

Today's episode is entitled Hot Diggity Dog Costco's New Weight Loss Program. But before we talk about Costco's weight loss program, we want to tell you a bit about the weight regain program we just started here in this office and I'm actually really excited about this because I've already talked with several patients who've joined our weight regain program. What's really special about this is that it's open to anyone in the country, Whereas previously we've been a little bit pigeonholed with who we could see based on insurance. So if you're out there listening and you want to join us to help with your weight loss, then you absolutely can Do. You want to tell them a little bit more about what all is included.

Dr. Weiner: 1:39

Yeah, so I mean we've been talking about this, want to tell them a little bit more about what all is included. Yeah, so I mean we've been talking about this and since we started the podcast we've had more and more people reaching out to us wondering if they can become patients in our practice, and we really want to be able to serve everybody we can. And so we sat down we said, all right, what's the best if we were going to design like the perfect program to really optimize people's chance to either lose the weight that they've regained after bariatric surgery or if they just are struggling with their weight, and maybe seeing if they can use the GLP-1s to lose a substantial amount of weight, what would that look like? What would we put together? So we decided we could probably get most people really on the right track with three visits with me and then three visits with Zoe, and then three visits with Zoe.

Dr. Weiner: 2:24

And then a big part of this too that we've developed a lot of expertise with over the last few months is the insurance approval for the GLP-1 meds.

Dr. Weiner: 2:29

And so we've kind of created essentially a priority program where people will make sure we'll do everything we possibly can to get people's insurance to cover the GLP-1 meds, and this takes writing appeal letters at times and making sure the documentation fits, digging through the medical policies and figuring out exactly what criteria required.

Dr. Weiner: 2:53

And so we're putting that all together and at the end of the session you'll get a written plan that says, hey, this is why you gain the weight or why you regain the weight. And here's our strategy. Here are the things that we think are realistic for you to be able to do to lose that weight and keep it off. We've got also some tools where we can help keep the cost low without using compounding medicines, using the real medications to keep your medication costs low. And then it also comes, of course, with the support groups that Zoe and I run, that we have about 25 of every week. So you'll get unlimited access for three months for the support group and then three visits with me, three visits with Zoe and all the insurance and other resources that we can direct to help you lose that weight and keep it off for good. So if you're interested, you can call the office or check us out on our website at poundicureweightlosscom.

Zoe: 3:44

All right Now getting into our in the news segment.

Dr. Weiner: 3:48

So this comes to us from ABC News and it's called Costco launches weight loss programs, including Ozempic-WeGovi, and I get people, my friends and family. They'll send me articles all the time and say, hey, what about this one? This would be a good one for the podcast. Or hey, did you check out this one? And I don't know what it was about this article, but, like every single person I know sent me this article, so clearly this is something that's interesting. But we've seen this before. We've seen this with gyms starting to do it. We've seen it with Weight Watchers buying Sequence Health and doing it.

Dr. Weiner: 4:24

And so what's happened is Costco's partnered with a really interesting company called Sesame. Sesame was started by a very bright guy named Marty McCary, who's a transplant surgeon at Johns Hopkins, and he essentially started Fiverr, but for healthcare. So Fiverr is one of these outsourcing companies where you can hire someone from anywhere in the world to do graphic design or computer programming or video editing or anything, and so they essentially took that and extended it to healthcare. So they offered it out to nurse practitioners, physician assistants, physicians who have some empty time in their schedule and say, hey, listen, you can set your own price and we'll put you on there and if somebody likes what you offer and they want to pay for an appointment, then you'll pay for an appointment, and so it's a very effective way to really cut through a lot of the bs and to lower the cost of health care, and so they've partnered with the costco's, partnered with sesame, in order to offer the service.

Dr. Weiner: 5:20

Um, I think there's some really good things, because it's going to increase access and it's going to do it at a really fair price. I think there's some other things to be careful of. The first thing, I think, is that there's a difference between obesity care and a prescription. Zoe, why don't you talk to us a little bit about that? What do we do in our practice, because most of this work really, quite frankly, comes from you. What do we do in our practice to help support people with GLP-1 meds?

Zoe: 5:50

Yeah. So how I like to describe it is we have this tool right, the powerful tool being the GLP-1 medication, which really helps jumpstart and propel that weight loss forward. But the tool by itself, although it might seem like it is not the end-all be-all, is not a magic pill, not a magic injection, and you will not get the best results or the longest-lasting results if you do not combine the tool with the lifestyle changes. So of course that's what we work on in our nutrition program, so that together the tool, along with those positive nutrition and lifestyle changes, really helps to facilitate and maximize the best results and to set you up for success in the long term. So the prescription is just getting the tool, whereas obesity care and comprehensive care is taking into consideration that whole picture and setting up for that long-term success.

Dr. Weiner: 6:45

And the two work together too right. You know, when you get the GLP-1 medication starting to circulate, all of a sudden it becomes much easier to make healthy food choices. And we've seen that there's a huge difference between a prescription and obesity care, because all of the trials the Wegovy trial and the Zepbound trial they demonstrated pretty substantial weight loss. We found that when that's used in real life and there's been a number of studies that have demonstrated that what's happening in real life is not what we saw in the trial. So we see a lot less weight loss in real life. Some of that's probably going to be because of interruptions in access in the trials that we see a lot less weight loss in real life. Some of that's probably going to be because of interruptions in access to the medications. But we also know that a big part of that is because a lot of practices out there aren't really implementing a very rigorous nutrition program and that, in our mind, is really a big part of success. It'd be great if you could just take the medication and lose the weight and then that was that. But that's not how it works for most people and the problem is it is how it works for a small percentage of people.

Dr. Weiner: 7:48

So if we look at the Surmount trial and again that's Zetbound, which is better weight loss than WeGoV we see about 50% of all the patients lose more than 20% of their total body weight, and we see about 32, 33% lose more than 25% of their total body weight. So you know, really we see about half the patients do exceptionally well with these medications. But there's another half who lose less than that and there's even 15% 10 to 15% who don't lose any weight at all or a very modest amount of weight. And so what we'll find is that with these kind of pay for prescription type programs, we'll see some people have an excellent experience and it will be amazing because their genetics lends them to losing a lot of weight on these medications, but we'll see other patients not lose much weight at all, and those are the ones that we really see in our practice quite a bit.

Dr. Weiner: 8:47

So it's a challenge. We try different medications, we push the nutrition, sometimes we move on towards surgery. But I think there's a huge difference between just providing a prescription, because we're going to be eliminating 50% of the people from really finding substantial success. 17% of all patients in the ZEP-bound trial lost less than 10% of their body weight, and in the Wegovy trial it was 30%. So there's a lot of people out there who don't respond particularly well to these medications, and this is with intense nutritional counseling.

Zoe: 9:20

So that number is going to be even larger in the real life, and and so we need to make sure that we're doing everything we possibly can to implement nutrition into people's success and post-op program yeah, and also something I wanted to mention was that I think a lot of people think with the big names like costco and weight watchers, that there's going to be some sort of magic stock or they're going to have their special dedicated stock of medication and that'll be cheaper and it'll be easier accessible. And that's just not the case. There's no magic program and just because you go to Costco or Weight Watchers doesn't mean that they have a better process of getting these medications.

Dr. Weiner: 10:01

In fact, specifically with the prior auths, they might have more challenges because they don't do it all the time, right. I mean, what expertise does Costco have in terms of-.

Dr. Weiner: 10:12

Hot dogs, yeah, hot dogs, but not getting prior auths. That's not something that they've done. Our office has a lot more expertise than Costco at getting these medications prior auth. I also think at the price tag $179,. I don't know how that's going to happen. My guess is that Sesame doesn't staff a whole cadre of MAs to provide this service and even if they do, there's so much work that goes into these prior offs right now that I just can't imagine them doing a particularly good job at this price point, paying the providers and then also paying for the prior auth.

Dr. Weiner: 10:47

Yeah, it's important to keep in mind that if we look at the size of these companies, so you look at Costco and you think, wow, what a big company. But let's compare Costco to UnitedHealthcare. I mean, it's a hundredfold difference in their revenue, and that really goes for Weight Watchers and certainly the gyms are even smaller. So you look at these big companies and you think, oh, wow, they're really going to be able to move the needle. But the truth is, nobody can move the needle against UnitedHealthcare. I think they're the ninth largest company in the world. Yeah, they're just enormous. And so these insurance companies are such a much larger scale than anything anyone else out there that, truthfully, when they look down, they probably look at us and Costco is kind of, you know, we look the same, just like when you get up on top of a tall building.

Dr. Weiner: 11:36

Some things that might be really different in size actually look the same from that perspective, and I think UnitedHealthcare may look at the world that way. So, anyway, this is interesting. I think it might serve some people's needs out there, but as far as it being kind of the they're going to take over weight loss, I don't see that happening. It's just way too complicated of a problem and there's going to be a lot of people out there who don't respond the way that they hope they would and at that point these programs aren't really going to be in a position to serve them and help them. All right, well, let's move into our patient story. We've got Suzanne here and she's a GLP-1 patient. Let's hear what she has to say.

Zoe: 13:02

All right, suzanne. Thank you so much for being here with us Welcome.

Sierra: 13:06

Thank you.

Zoe: 13:07

Yeah. So we would love for you to start off just by telling us your story. Why don't you start from before you started with our practice? Go back as far as you want to, but just kind of share with us about your maybe struggles with weight and what you've tried in the past. Okay, sure.

Sierra: 13:26

Well, overall, growing up, actually, I really didn't struggle with weight. I was kind of a tomboy and I played a lot of sports. I did a lot of running, I did volleyball. I did a lot of different things. When I was in high school. I got pregnant in high school, so that was the beginning, probably, of any weight issues that I had at that point. I was like a size three at the time. I got pregnant at 16 years old, so I had my son when I was 17,. Actually, I struggled with a little bit of weight at that time. I actually lost most of the weight after that and through my 20s I was happy with where I was at and then, as I got into my 30s, that's probably when I noticed more changes in my body but also in how I felt. And I also have a very sedentary job and so it's an office job. It's nine to five, sometimes more than that.

Sierra: 14:19

And so you know, struggling to find time. Time is always an issue, I think, with a lot of people. So and then, as I was still pretty okay at that point, I'm still exercising fairly regularly. I will say my diet at the time probably was not the best. I also ended up with another pregnancy at the age of 40. You really kind of bracketed that at both ends. A little bit, yeah, a little bit of a stretch there between my children, my thoughts on pregnancy.

Dr. Weiner: 14:47

Is that pregnancies at very young and very, you know, relatively older ages are major weight gaining events. So, you kind of you, you kind of nailed both of those.

Sierra: 14:56

Yes, I did Not on purpose though, Dr Weiner, but you know so. At age 40, you know, I had my daughter, who is going to be 10 this year, and am about the size now that I was when I got pregnant with her.

Sierra: 15:11

And so that was 10 years ago and slowly after that, after I had her and not intending to blame her in any way but my body obviously changed and I got older and the weight gain came afterwards and I gained probably close to 70 pounds, which is a lot. And so probably a couple of years ago actually, before I met you or before I decided to meet with you, I tried many different things Atkins diets, keto diet, starving myself, fasting, not eating, just, you know, kind of desperate to find a solution, and it was just a struggle. And then, I don't know, a couple of years ago, I really dedicated myself to doing something about it and stop, you know, making excuses about time and nutrition and different things like that that if I wanted to change, I had to be the one to change it. I think I met you in November of 22,. Probably about six months prior to that I had worked on, I had lost about 30 pounds on my own. By the time I met you I had gained, I think, 12 back. But when I met you, you know, one of the things we talked about which I was so grateful for was bariatric surgery was an option. But because I had done so well on my own and what I really appreciated from you and Zoe and your team is that, the encouragement for me to try to do it without surgery and that I might need just a little bit of help. And so I think you think to send it was the first prescription I got back in November of 22. And I think I lost I don't know, it was like eight to 10 pounds from that and then we moved to Wagovi, I think in February of 23. And part of the reason you wanted to put me on Wagovi from the beginning, but there was a shortage in supply.

Sierra: 17:00

I was again seeing a lot of success at the very beginning and then I plateaued, probably for the last four months. I didn't gain anymore, but I was steadily within one or two pounds and the goal that I had in mind it just felt like I couldn't hit it, or two pounds and the goal that I had in mind, it just felt like I couldn't hit it. And, Zoe, thank you for all the encouragement you did, Because, because I had been so successful at that point, it was really difficult not to give up, Because it's like you just sit there and you're like, oh my gosh, I'm still doing everything, I'm going that extra mile and doing different things. I ended up joining a Pilates class that was encouraged by Deidre, who's on your team, and then in January I joined boxing and it sounds worse than it is really. It's boxing and booties, so that's the name of the class. It is an hour workout, pretty strenuous, Since I've done those and introduced kind of those things in my life, plus the things I do at home.

Sierra: 17:54

I have a rowing machine, I have a stationary bike. I do have weights as well. That I added in, encouraged by you, Dr Weiner. And am I exactly where I want to be? No, but I have now lost 74 pounds. So that's where my total is. The good news is I'm back. I'm actually now below where I was when I got pregnant with my daughter 10 years ago Wow. So that's where I'm at right. Now. I have 36 more to go. My overall goal is 110 pounds.

Dr. Weiner: 18:24

What was your starting weight, Suzanne?

Sierra: 18:25

It was north of 200.

Dr. Weiner: 18:28

Okay.

Sierra: 18:29

But the good news is 74 pounds. I feel better, confident. I feel that I can reach my goal of 110 pounds.

Dr. Weiner: 18:37

Yeah.

Zoe: 18:38

And what I really like about what you've been able to incorporate exercise-wise is you've done things that you enjoy. It might not be what people automatically think of right Boxing class or Pilates but you found these things that you genuinely enjoy and look forward to doing and you like the way it makes your body feel. And I think that's something we've talked about is finding what it is that you enjoy, and so you continue to do it and you've done that.

Zoe: 19:07

I was telling Dr Weiner yesterday that we ran into each other both wedding dress shopping, and what a fun experience that was.

Sierra: 19:15

Yes, yes, that has come about in between all of the meeting Dr Weiner and starting my journey and I met. His name is Mike and I met him last summer and we are getting married next year. But the great thing about him is that he is supportive of me, no matter what. He loves me the way I am. I've lost quite a bit since I met him and he's very, very supportive and my family's been supportive. My daughter is supportive, it's just really great to have that.

Dr. Weiner: 19:46

It makes such a huge difference. You know I talk to patients. We've got patients in our practice on every end of the spectrum right. We've got people like you who really have a lot of support from your daughter, from Mike, from everybody surrounding you and it just makes it such a smoother, easier, more positive process. I found that you know if you're really going to be successful at this, you need somebody right. Whether it's a friend or a family member, whether it's someone else who's had the surgery or is using the medications, whether it's our peer leader, somebody else in our program. You need somebody to get through this. It sounds like you're very blessed with that.

Sierra: 20:29

I am.

Dr. Weiner: 20:29

Yeah.

Sierra: 20:30

I'm blessed in many ways. So funny too, because now that I am getting married and ran into Zoe at the wedding dress shop, it's added to my journey, it's added to my goal. I have a very beautiful wedding dress and it's getting alterations as we speak to wear that with confidence where probably two or three years ago I wouldn't have even I would have been like we're going to the courthouse or you know we're not doing that and we're actually having a very beautiful wedding. But it's been a good inspiration too. It's just it's helped to keep me going. I actually finally, the last, I think, six weeks I have been under that goal, that initial goal weight. I've set a new goal but I've been under maintained on average under that goal weight. That I couldn't get to for four months, for six weeks now. I mean, I weigh myself every day. I record it. I actually have a special scale that records it and sends it to an app.

Sierra: 21:26

You know the medication. Thankfully I didn't have any side effects, but I think the great thing about it is that it really helps with the appetite suppression and then it helps you change your lifestyle. So and the thing I love about it is I'm not depriving myself. I, and I think that's why I've been able to maintain it for as long as I have, and even though it's been a slow journey, I think that's good, and I think it's because I don't deprive myself. I don't feel like I'm depriving myself. So there are times where, yes, I might have dessert. Now will I have a big dessert, like I used to have? No, but you know, there's nothing to say that you can't still eat some of the things, and so I change the way I do things and look at food, and it's not my enemy. It used to feel like it was my enemy and it doesn't now. Thank you for that.

Zoe: 22:16

And I just wanted to say, first off, how much you deserve to have the beautiful wedding of your dreams. I'm so happy that you are doing that and also how proud of you I am, because you have worked hard and you've been very diligent about meeting with me and you've made so much progress and it's just been such a joy to be a part of your journey, suzanne. Thank you, zoe.

Sierra: 22:41

Yeah. And I can't wait to see you get married either. I can't wait to see the truth. Two weeks, two weeks. I know it's not that far away.

Zoe: 22:49

It's not that far away. Well, thanks so much for being here. We really appreciate you sharing and I'll be talking to you soon.

Dr. Weiner: 22:56

Absolutely Thanks, Suzanne Sounds good.

Sierra: 22:59

Thanks, dr Wendell, thanks Zoe, absolutely Bye-bye, Bye-bye.

Zoe: 23:02

All right, that was so great. Thanks to Suzanne for coming and sharing her story. And now we want to move into the nutrition segment. So what I have for you today has to do with forming new habits.

Zoe: 23:15

Okay, so forming a new habit is the hardest part, but that is really the mindset and what we work towards in our program. Right, there's not an end point of I'm going to do this diet for two months and then ending it. This is a lifelong commitment and that actually mindset shift allows you to show yourself some more grace and patience, knowing that it doesn't all have to happen at once. More grace and patience, knowing that it doesn't all have to happen at once. Now, going back to our nutrition segment, is this concept of using a anchor habit or a trigger habit to attach your new desired habit to. So taking something that you are already doing in your day and attaching the new desired habit to it to reinforce that habit formation. So an example of this is every day, maybe you have coffee, right, and I know you have coffee Every day, every day.

Dr. Weiner: 24:09

I have coffee 365 days a year, Right so?

Zoe: 24:12

while you're. Maybe your new habit is adding in a movement sprinkle. So maybe it's. You are waiting for your coffee to brew and while that's happening you do 10 squats because you've got the trigger and then you have your new habit. Or something else that I talk about is if you're trying to increase your water intake and I always tell people, bring that water with you everywhere on your errands, in the car. So if it's trying to find an anchor habit while you're in the car is, every time you stop at a red light, use that as your trigger to take a sip of water, and then just finding these little moments in your day that you can easily attach your new habit to it definitely makes it easier.

Dr. Weiner: 24:49

Yeah, I love that. That's actually a pretty common technique in medication compliance teaching. So for patients they would do this a lot with like transplant patients, where missing a single dose of medication can be very dangerous is they'll? They'll work with the patients and say, okay, well, let's look at your, your habit of brushing your teeth every night and let's make sure you, you know these are the pills you take when you brush your teeth. And let's look at your morning coffee, and these are the pills you take with your morning coffee. They found that by by anchoring them to these preexisting habits, that they have a higher compliance rate. So there's actually some pretty good data out there in medication compliance and I believe in the transplant world to support this. So I think you can use it for anything and I think this is a great, great tip and one I think our patients will really benefit from.

Dr. Weiner: 25:35

All right, so next segment is the economics of obesity. This is a topic I've been talking about doing for a while and I really dug into it and learned about it and I broke it up into two parts. So it's our first two-part series that we've got on our podcast and we're going to talk about drug patents In part one I'm just going to explain the drug patent process and how sometimes it's gained, and in part two we're going to talk specifically about ozempic or semaglutide and how that patent has been extended. So drug patents are 20 years in the US, which means from the time you file a patent, you can sell that drug exclusively for 20 years. So let's first talk about why we do have patents. So patents are designed to encourage innovation and encourage research and encourage companies and people to spend time and money in developing things so that they can have an exclusive right to sell them. And it's very expensive to bring a drug to market. It takes about $1.3 billion on average to bring a drug to market and so it's important that we have these, because we need companies to create these medications so that they serve the public. So it really is designed to serve the public good. But we also have to understand that when one company, and one company alone, has the exclusive right to produce a medication, that will increase the cost of the medication and that is bad for the public, because the lower cost the medications are, the better it is for the public, and I think anybody who's ever tried to get some GLP-1 medications and had to shell out 500, 600 bucks for it. If it was 50 bucks, they'd be a lot happier about that.

Dr. Weiner: 27:22

So there's this shift, there's this pendulum where the longer the patent is, the better it is for the drug company. The shorter the patent is, the better it is for the patient, to a point, as long as it doesn't decrease innovation. And we're seeing right now that pharma stocks are at all-time high. This really shows me that we're probably shifting a little bit more toward the pharma side. And even though the patents are 20 years and that hasn't changed, the truth is there's been a lot of change in the gaming of the patent system, and we see about two thirds of all drug patents are for drugs that are already on the market, which means that they're filing multiple patents for the same drug.

Dr. Weiner: 28:08

Why would you do that? Because it's a technique to extend the life of the patent. And so, yeah, sneaky. So we see them create a slow release version. We see them create what are called isomers. Isomers are just mirror images of the same molecule.

Dr. Weiner: 28:27

We saw this a lot with the proton pump inhibitors for acid reflux or acid reduction, where they would release. Once omeprazole was reaching the end of its patent. They released Prevacid, which is essentially an isomer of omeprazole, and it's not in the active site. So it's like they changed a little thing. It would almost be like changing the color of a knob on a dishwasher. Right, it's not going to change how the dishwasher works, it just is a slight appearance change and so. But by doing that they can get a whole new patent for a whole new drug and then market that, and patent for a whole new drug and then market that. And so they'll also see combination medication. So we've seen this with Contrave, which is Welbutrin, and Naltrexone, which are two medications that have been off patent for decades. They patented a couple of years ago as something called Contrave for weight loss, and so the combination was patentable and they were able to sell it at a pretty substantial markup. There's a lot of other gaming that they do for this, where they'll maybe get a very broad patent at first, and then that will protect them, and then years later they'll get a more specific patent for the medication, and that's the one they point to and say well, nobody can make that medication. By doing that they extend the patent substantially.

Dr. Weiner: 29:39

There's currently a battle in DC to develop what are called march-in rights, and march-in rights essentially gives the government the right to license a technology to another party. So the government could go to Novo Nordisk and say, hey, listen, this semaglutide, ozempic stuff is too good. I'm going to give a license to a generic drug manufacturer because you guys clearly can't make enough of it and it's costing people lives and I'm sorry, you're still going to make a lot of money, but we're going to also allow a generic company to manufacture this. There's a battle over whether that's right or wrong, and I do. I see both sides of this argument. I mean, I understand that we shouldn't necessarily allow our government to do that, but at the same time it would also make a big change in a lot of people's lives.

Dr. Weiner: 30:28

This is a complicated problem, but it's very clear that the pendulum has shifted toward the pharma industry. We kind of have another David and Goliath scenario here too, where we have the generic drug manufacturers and the pharma industry, and when it comes to a legal battle, there's just no comparison between the size and the budget of these two types of companies, and so, anyway, this is complicated. Next week we're going to talk about how this really related to Ozempic and when we can expect to see semaglutide available as a generic option. So complicated topic. I hope that clarified things a little bit and if we were able to see some improved access and more competition in this market, I think it's just going to help everybody out. All right, why don't we move on to our social media questions? We've got Sierra here to read the questions to us. Fire away with our first question.

Suzanne: 31:24

Okay, first question is from Raphael, from our website. What is your opinion about homemade pizza with cauliflower crust, veggies and vegan cheese?

Zoe: 31:34

I have a couple thoughts here to share. I do think this is a great option to share. I do think this is a great option. Number one I would prefer that you make your own cauliflower crust rather than buying the frozen ones, because the frozen ones still have a ton of ingredients. There's still going to be some starchy components in there and whatever else.

Dr. Weiner: 31:52

How do you make a cauliflower crust?

Zoe: 31:53

Well, I'm glad you asked. I've done it a small handful of times. So basically, you put cooked cauliflower in the blender. You can put an egg, some Parmesan cheese, some seasoning and whatnot, blend it up into kind of a paste, spread it out on a-.

Dr. Weiner: 32:09

Seems easy.

Zoe: 32:10

Yeah, yeah, it's not going to have the same crispy texture as a regular pizza crust, but you still get the same effect. And then, of course, adding veggies amazing, beautiful. I would recommend maybe adding some protein source on there too. Now, with the vegan cheese, unless you are vegan, personally, I would recommend going for some part skin mozzarella on there. It's going to be less positive If you take a look at the vegan cheese or any vegan yogurt, all of it. I mean, it's a huge ingredients list. There's a ton of it's very processed, lots of processed ingredients, and unless you are vegan or don't want to have cheese for an allergy or something like that, I personally would recommend going for the less processed mozzarella cheese. What do you think about?

Dr. Weiner: 33:00

that I've seen some vegan cheeses that are based very heavily on nuts and I've seen some recipes for them and I remember thinking, well, that's not such a crazy recipe.

Zoe: 33:09

Oh like make it yourself.

Dr. Weiner: 33:10

Yeah, so once you start getting the vegan cheese, 95% of those are going to be super processed, but I do think there is some way to make some type of cheese alternative. You may have to make it yourself, but I've seen that been done with nuts, like cashews especially, I've seen, and it looks interesting because you know, cheese is essentially protein and fat and nuts are essentially protein and fat, and so you know there's going to be kind of the same macronutrient makeup. So it's interesting. I don't know. I think if anybody out there has some good experience with either vegan cheese or cauliflower crust or some recipes, feel free to shoot them over to us, post them on social media, tag us, whatever. I'd love to hear what you guys are doing with this, Because I think with all of this stuff it's nuanced. You know you can do this right and you can do this wrong.

Dr. Weiner: 34:00

And there's a whole spectrum, lots of gray area, yeah a lot of gray area on this one, but I do like that. There's a lot of effort in this. Someone's like I'm going to figure this out. There's a way for me to eat healthy but still enjoy my food, and so I think I support fully the spirit of this question.

Suzanne: 34:18

Okay. Next question came in by email. I'm on Contrave. What are your thoughts on this medication?

Dr. Weiner: 34:25

Kind of interesting. This question appears on our drug patent conversation right Because.

Dr. Weiner: 34:29

I just mentioned about Contrave being essentially a patent game. So I think first of all, that's important. That's where where does come from. This drug was not created in order to help people lose weight. This drug was created in order to make money. That's where it came from. They took two drugs Welbutrin and Naltrexone. They got pretty clever because Naltrexone is produced as a 50 milligram pen and they put like 10 or 15 milligrams of the Naltrexone in. You can break a pill in half, but once you start breaking it in quarters it gets pretty sloppy, and so I think they put a relatively small dose of naltrexone in.

Dr. Weiner: 35:05

Naltrexone is an opioid blocker, like if you were to take Percocet or a similar type of medication. It blocks that receptor, so it doesn't work at all. The truth is, contrave does not work particularly well. We do use a little bit of it in our practice, but only for patients who cannot get GLP-1 medications. Just shy of 50% of patients on Contrave lost more than 5% of their total body weight. So 50% of people lost zero zippo pounds, and that was compared to 23% of placebo. 23% of the placebo group lost more than 5% of their total body weight and 50% of actually a little less than 50% of the actual drug group lost it, so it's really really marginal weight loss.

Dr. Weiner: 35:51

There is a risk of suicidal depression with Contrave and so you have to be careful if you are taking that. In general, younger patients will not tolerate this well. We see a little bit better tolerance in people over 65. If you're already on an SSRI like, let's say, you take Prozac we can't stack a second one because Wellbutrin has a similar effect to Prozac and Citalopram and all these other medications out there, so there's some restrictions on who can take it. It doesn't work that well If you ever need pain medicine, it won't work while you're taking this until the naltrexone wears off. So yeah, it's out there, but I really look at this medication as something that's good for the pharma industry but not so good for patients. But every now and then we have someone lose weight on it.

Suzanne: 36:39

Okay, last question here is from Kristen, by email. I would love a podcast on the diagnostic pattern of dumping syndrome, the difference between early phase and late phase and what can be done from a dietary standpoint and when to seek help.

Dr. Weiner: 36:55

I'm going to talk about the difference in dumping syndrome in early and late phase. The first dumping syndrome from an early phase and that's kind of what most people really consider dumping syndrome is I eat something fatty, greasy or overly sugary. It was originally described with sugar and it's because when we dump it into the small intestine the high sugar concentration can pull water out of the small intestine rapidly and can cause low blood pressure, sweating fast heart rate, abdominal pain. We also see that same effect with fatty or greasy foods and this is really classically used to describe an experience that occurs after gastric bypass. It's not something that we see after sleeve, because you need to rapidly dump whatever you're eating into the small intestines and we don't do that with a sleeve. We still have a pylorus, so things take a little more time and they go the natural route. They don't bypass the first portion of the intestine and so that's what early dumping syndrome is. It's just real food intolerance and discomfort that you see with fatty, greasy or sugary food.

Dr. Weiner: 38:05

Now the late phase of dumping is, in my mind, really a very different process. It's a very different pathology that they've kind of lumped into dumping because it has some similar features from an experience, but from a physiology perspective it's actually very unrelated, and this has to do with hypoglycemia and, again, mostly after gastric bypass. Every now and then we see sleeve patients have this experience where they eat a processed food and it causes an over release of insulin, so initially they have a blood sugar spike and then their blood sugar plummets down the road and that typically triggers you to eat more processed food, which which causes it to go up again, and people can ride this roller coaster all day long. So that's dumping syndrome. So, zoe, talk to us about what you can do if you're experiencing these types of symptoms, because sometimes, especially early after surgery, it can take just a little bit of food to experience it.

Zoe: 38:57

Well, you mentioned the types of food that can cause this. So preventatively we want to avoid those foods. Of course I also would recommend, if you are having something sugary, let's say pairing it with protein so that it helps with the slowdown of the absorption and the digestion and also with the stabilization of blood sugars. And then also, if you are experiencing that low blood pressure, maybe some lightheadedness, just take a beat, sit down and maybe drink some water and just kind of take it easy until you feel better, but again not going to that other extreme of eating more processed foods, eating something nutritious and fiber and protein rich.

Dr. Weiner: 39:41

Yeah, what about the hypoglycemia? What can you do for the hypoglycemia? What do you recommend for patients? You've got to see a lot protein rich. Yeah, what about the hypoglycemia? What can you do for the hypoglycemia? What do you recommend for patients? You've got to see a lot of that. Yeah, I see more of that than I see early dumping. I don't know what your experience is.

Zoe: 39:51

So if we think about that blood sugar bottoming out, we want to bring it back up and I think many people have heard like, oh, I should drink a little bit of soda or I should have a little piece of candy. We don't want to do that. So maybe you have like a half a banana with some nuts, or you have some applesauce or something that is going to give your body that glucose back in the blood, but not in a way that's going to create a spike, by pairing it with some protein and making sure that that sugar, if you will, also has fiber attached to it by utilizing fruit yeah, I think protein and making sure that that sugar, if you will, also has fiber attached to it by utilizing fruit.

Dr. Weiner: 40:25

Yeah, I think protein and fiber is really the antidote to actually both these problems. Right, the early dumping syndrome if you're eating a lot of protein, or what you're eating has a lot of fiber, then if there is a little bit of this toxic stuff on it, you probably still won't have the same experience. And for the hypoglycemia, that's the best way to keep your blood sugar from spiking, and it's the initial blood sugar spike that really triggers this. That's, I think, a great, great recommendation. And I think dumping syndrome is something that a lot of gastric bypass patients are fearful of, but it really is something that's very manageable. It's very, it's very preventable and you know, when you pair it with a metabolic reset diet or a really healthy way of eating, eating is very comfortable after a gastric bypass.

Dr. Weiner: 41:10

So that wraps up our podcast. This podcast is produced by Sierra Miller and Rhiannon Griffin, and the editing is done by Autogrow and Vincent See, and a special thanks to our guest guest, suzanne today. So please check us out on social media, our website, or consider joining our online nutrition program or weight regain program if you need some more personal assistance. We will see you next time.

Zoe: 41:32

Yeah, take care.