The Pound of Cure Weight Loss Podcast
Ozempic, baby!
Join us as we dive in on our most recent episode of the Pound of Cure Weight Loss Podcast titled, Ozempic, baby!
Episode 27 kicks off with our In the News segment where we discuss an article by CNN that discusses how GLP-1’s are increasing fertility. This comes as no surprise considering we saw the same results after weight loss surgery. So why do GLP-1’s and weight loss surgery cause increased fertility? Tune in to find out!
In our Patient Story, we talk to Lacey who came to us for help after she regained weight approximately 7-8 years post gastric sleeve. We got her on a GLP-1 medication and she has since lost all of her regain and is back to her postop weight. She is now considering creative dosing strategies for weening off the meds and we offer advice on how to do this without regaining weight.
In our Nutrition segment, Deidre offers advice on how to eat at restaurants and enjoy your meal without destroying your weight loss progress. There are 2 different approaches and frequency is key.
Finally, we answer our listener’s questions including, whether or not Trulicity damages the Vagus nerve, will a revision cause additional weight loss, and our thoughts on the product label statement "Discontinue Ozempic in women at least 2 months before a planned pregnancy".
Join us as we dive in on our most recent episode of the Pound of Cure Weight Loss Podcast titled, Ozempic, baby!
Episode 27 kicks off with our In the News segment where we discuss an article by CNN that discusses how GLP-1’s are increasing fertility. This comes as no surprise considering we saw the same results after weight loss surgery. So why do GLP-1’s and weight loss surgery cause increased fertility? Tune in to find out!
In our Patient Story, we talk to Lacey who came to us for help after she regained weight approximately 7-8 years post gastric sleeve. We got her on a GLP-1 medication and she has since lost all of her regain and is back to her postop weight. She is now considering creative dosing strategies for weening off the meds and we offer advice on how to do this without regaining weight.
In our Nutrition segment, Deidre offers advice on how to eat at restaurants and enjoy your meal without destroying your weight loss progress. There are 2 different approaches and frequency is key.
Finally, we answer our listener’s questions including, whether or not Trulicity damages the Vagus nerve, will a revision cause additional weight loss, and our thoughts on the product label statement "Discontinue Ozempic in women at least 2 months before a planned pregnancy".
because it's a huge problem if you've lost 60 or 70 pounds on these meds and then you stop taking them and become pregnant, you can gain 40 pounds in that first trimester. All right, this is episode 27 of the Pound to Cure Weight Loss Podcast, ozempic baby. So Zoe's still on her honeymoon, so we've got Deidre here again, and so Deidre, our patient guest today, is one of our co-workers in the OR.
Deidre:Oh, yes, perfect, I love serving our TMC friends.
Dr. Weiner:So Deidre runs essentially a GLP-1 clinic in the OR. She runs it between cases. When we do cases it's usually like about 45 minutes or so in between from one procedure to the next while they clean the room, and so Deidre usually makes rounds in the OR talking to everybody. Our hospital covers the GLP-1 medication. They cover both Zepbound and Wendel. Yeah, they everybody. Our hospital covers the GLP-1 medications. They cover both Zepbound and WeDo.
Deidre:Yeah, they actually have really good coverage for GLP-1 medications If you're a.
Dr. Weiner:TMC employee Deidre knows the policy inside and out.
Deidre:I know all of your insurance plans. I know what covers what?
Dr. Weiner:How do you?
Deidre:use the coupons. What's the best plan? Which one? The teal is really good, the good, the purple is pretty good, so yellow used to be good, so anyway.
Dr. Weiner:so Deidre runs the OR clinic.
Deidre:And I think that's something you know that that a lot of us take pride in is that we take care of each other.
Dr. Weiner:I mean, our staff helps us, so we want to help them.
Deidre:Yeah, that's why I do it.
Dr. Weiner:Yeah, so so there's been a lot of people looking really good lately in the OR right. You know. Definitely some people have lost some weight and I think a lot of that's thanks to Deidre. So if you're out there and you're a regular listener to our podcast, we'd love it if you would rate us and give us a review that helps get the podcast out to other people and so that we can share this message of inclusiveness and of a shame and blame-free treatment of obesity and making sure that everybody gets the important information that they need to make the best choice Be successful in the weight loss journey.
Deidre:And to be successful, yeah.
Dr. Weiner:So let's move into our In the News segment, and this is where our title comes from. This is from CNN and it's called Ozempic Babies. Reports of surprise pregnancies raise new questions about weight loss drugs. So this story is actually about a patient who was taking Monjaro, not Ozempic, but what we're finding is that Ozempic has essentially become the Kleenex of facial tissue. So the technical name for Kleenex is a facial tissue, but everybody just calls it Kleenex which is actually the brand.
Deidre:The brand name just stuck. Yeah, the brand name stuck.
Dr. Weiner:All GOP1s now are Ozempic, and so yes, exactly All GOP1s are Ozempic, and so this article really shows that, because they're talking about Monjaro, but they call it Ozempic baby. But it was really a Monjaro right. Increased risk of fertility.
Deidre:Right, and also it's never been studied for increasing birth defects, and so you also can't take it with pregnancy or before becoming pregnant.
Dr. Weiner:Yeah. So that's really something that's very important and we're going to talk quite a bit about that in today's episode is that GLP-1 medications no GLP-1 medications are approved for pregnancy, so it is on the Monjaro package insert that there is an increased risk of fertility. We talk to all of our patients of childbearing age about not relying on oral contraception, on using barrier contraception or IUD or something along those lines, and so this article talks a lot about PCOS. Deidre, why don't you talk to us about what PCOS is and how it's related to obesity?
Deidre:So PCOS kind of has two main factors One is insulin resistance, right, and the other is overproducing androgensens, right. So your body overproduces androgens like testosterone and progesterone to some extent, and that causes you to have a decreased sensitivity to insulin. Because of that, your pancreas produces more insulin to compensate for the decreased sensitivity and insulin resistance. And insulin is a weight gain hormone, and so you start to gain weight.
Dr. Weiner:So it becomes kind of this vicious cycle, and it's a cycle because the fat cells are what are producing most of the androgens right right, but the fat cells produce androgens and estrogen and so, as you, gain weight, your body actually produces both more androgens and estrogen, which disrupts your menstrual cycle and ovulation and so decreases fertility.
Deidre:And so many times with weight loss you improve the insulin resistance and so that decreases the amount of androgens you're producing. Right, that is in the cycle. With the amount of androgens you're producing you have, you produce less estrogen and the hormones are more balanced and you can start having periods again, you can start ovulating again and people and it's easier to get pregnant because of that.
Dr. Weiner:So so we've known about this for many, many years. I've had, you know, probably a dozen or so patients become pregnant within the first six months after bariatric surgery, More than that.
Deidre:I've seen three or four like in the last month. I'm not even. Yes, we tell everybody.
Dr. Weiner:It's 18 months before pregnancy is acceptable after bariatric surgery, and I've seen this a number of times and I've actually seen only healthy babies as a result of this. So we're seeing the exact same thing with Ozempic and all the other GLP-1s that there's an increased chance of fertility with these medications Because of the weight loss.
Deidre:I mean, it's the same concept, Right? You're producing less estrogen and so that helps with the hormonal balance, which allows you your periods become more regular. And a lot of times patients after bariatric surgery and after losing weight on these medications will have heavier, longer periods for three to four months until their menstrual cycles and their hormonal balance starts to level out as the weight loss starts to slow down.
Dr. Weiner:Yeah, so it's recommended that you stop these medications two months prior to trying to conceive. That's our recommendations. That's the official package recommendations. When it comes to pregnancy, honestly, we just don't mess around Like the rules are the rules. We don't bend the rules we don't. There's no, you know, a wink and a nod Like yeah, it'd be better if you did.
Deidre:Yeah, it hasn't been studied until it's better to just kind of err on the safe side.
Dr. Weiner:Yeah, this is not something you want to mess with, because you're not even messing with your own life, you're messing with your child's life. So another thing that's tricky with this is that a lot of the symptoms of pregnancy and PCOS overlap Right, right, yep, bloating, nausea, amenorrhea and not having periods, and so sometimes patients are having, are pregnant, don't know it.
Dr. Weiner:They think, it's just a regular PCOS Right, and so they're continuing to take the medication. So, but there's one thing that we're seeing without question, which is that Ozempic and other GLP-1 medications is a very powerful fertility medicine. Right, yes, absolutely, that's really interesting to me also from a coverage perspective, because a lot of Insurance policies have fertility coverage and they'll pay a certain amount of money or pay toward things that will provide coverage for fertility. And so the question is will Ozempic be covered as one of these medications?
Deidre:Right. I mean that would be fantastic, because it's not just the weight loss which insurance companies might balk at, but improving the insulin resistance is huge. And these medications were made for diabetes. Their job is to lower your blood sugars. That's what they were designed for, and so just by taking these medications by default, you're going to have less insulin resistance, better control of your blood sugars, and that helps fertility, yeah.
Dr. Weiner:So I think this is something that we're going to talk more about the safety of pregnancy, because that is, in my mind, that's really the complicated issue, right. Is you know, if you're of childbearing age and you're starting a GLP-1 medication, what's the right thing to do there? And we'll talk more about that later in the show. But this is a really interesting story because we just keep seeing this. A couple episodes ago, we talked about sleep apnea, right, we're seeing it with non-alcoholic fatty liver, cardiovascular risk reduction, cancer risk reduction. We're starting to see all these really great benefits from these medications and this also, to me, really just solidifies the fact that these medications are here to stay, that we're not going to find out about some freak side effect three years down the road, where everybody who's been taking these medications is going to die an awful death or have some terrible thing. We see this with all of these medications. I think we've talked in the past Bactrim, right Stevens-Johnson syndrome.
Dr. Weiner:For those of you who don't know what Stevens-Johnson syndrome is, it's when your skin falls off. It's a terrible, terrible problem, and yet we know this. We see this with Bactrim, but yet we still prescribe.
Deidre:Bactrim and aspirin. And aspirin too Is what causes it. You're right, and aspirin's been around forever. Aspirin we see it too Right. And so we understand that there and the reduction of comorbidities on so many levels is what's going to make these medications last for the long term and hopefully what we'll get coverage to.
Dr. Weiner:Remain a mainstay of treatment of metabolic disease. Yeah, just as we keep adding more and more and more of these comorbidity benefits, it would outweigh any issues that would pop up down the road with these random and rare side effects. Right right, so all right. Well, let's bring Lacey on. Lacey is part of our OR clinic that Deidre has been managing.
Lacey:Yeah, she's been super successful.
Dr. Weiner:Her weight loss has been super successful, so let's bring her in and hear her story, all right? Well, let's welcome Lacey to our podcast. Lacey works with us in the OR podcast.
Lacey:Lacey works with us in the OR and she's also part of Deidre's OR clinic that she runs in between cases.
Dr. Weiner:So, lacey, why don't you just tell us your story of your struggle with obesity and when you kind of started your treatments and how this has all worked for you?
Joel:I think it really started after I had my child at a young age, in college and then I had it was a surgical check in the OR and from 2008 on, and then in 2012, I decided to have a gastric sleep.
Dr. Weiner:Okay.
Joel:So, and then that I lost in the first year a hundred pounds.
Dr. Weiner:What'd you start out and what'd you finish at? I?
Joel:started out at 250 pounds.
Dr. Weiner:Okay.
Joel:Pre-surgical weight. And then I got down to 150.
Dr. Weiner:Right, you're like, I did it, yeah, and then I won Rebounded a little bit, so I got a maintained 170.
Joel:to 180.
Dr. Weiner:And you had that done in the U S. Yes, yeah, texas had that done in the us. Yes, yeah, texas texas got it okay and you're a tech and you work in the or regularly, so, yes, you understand you got to go to the right place. Yes, yes I watched many proceed, many procedures done before I decided you got to pick your surgeon based on how he or she did exactly yeah, I watched and I studied it a lot before I even made that decision.
Dr. Weiner:Good, good, okay. So you lost almost 100 pounds, rebounded some. Now how was your nutrition after that sleeve? You know, did you get a lot of counseling and guidance on that?
Joel:Yeah, but mostly Like an OR clinic.
Deidre:Like yeah, because.
Joel:I mean that's kind of the perk of the job, right?
Deidre:We just get to come in and ask questions whenever you guys want.
Dr. Weiner:Yeah, yeah, yeah yeah, so, yeah, I did that and, um, I was in the or and so we just I try to do meal prepping as much as possible, but, as you know, yeah, especially in a hospital setting it's so hard to wear like those bad foods, and you know yeah, when you're first assist, you can't exactly take a break right, right, you know it's not like someone else can just pop in and take over for you the other. Like the circulating nurses and the techs who hand the instruments, they are able to get a break.
Joel:But, the first assist can't no, right, yeah, yeah, we don't get a break either.
Dr. Weiner:No, yeah, so so. So that kind of leaves you off in short of time and sometimes you're going from one room to another, you're going to help this surgeon in room five, and then what's? Convenient and fast, and so you're grabbing a bag of something.
Deidre:Also you're starving because you've been in a long case.
Dr. Weiner:Yeah, yeah and so. So your job kind of lent itself to not as great of eating, and that slipped. And and there's another issue, which is that you're you know everybody in the or kind of there's a lot of people who kind of have their thing, that they do, and your husband is pretty much known as the barbecue king he also works in the or with us, and so so there's a lot of, you know, barbecue, unhealthy food, so so that probably contributed a little bit to some of the weight gain, right For sure.
Dr. Weiner:So then you kind of you know, you moved here to Tucson, you started working with us and you joined our OR clinic.
Joel:Yes, yes, I moved here in 2018. So I noticed around 2020, it was about eight years post-op that my weight was getting back up again so you held it off for about seven or eight years.
Deidre:Yes, yeah which is very impressive.
Joel:That's pretty good after a sleep yeah, and I remember, I still remember coming and talking to you and be like how long does a sleeve last?
Deidre:is it?
Joel:forever and you said about seven to eight years and I said, yeah, I'm there yeah, yeah, and I felt it coming coming on again, so it was very like um so what did that feel like?
Dr. Weiner:You know, how did you know? I think two things first, from just a basic hunger, and how'd your body feel? But then also, how about the emotional side of that?
Joel:I was very, um distraught, just like very discouraged, because I went through this procedure, Um, and I was doing so well for so long, moving a new job, new, whole new state all new people, all the stressors came in and I just did not handle it well and just started emotional eating. So, it was. I think it was definitely all in one.
Dr. Weiner:Yeah, all tied together, all probably around the time the physiology was starting to wear off too Exactly, you know, kind of perfect storm, and I felt like it happened overnight, like it, just like came back overnight.
Joel:I didn't get quite as big. I think whenever I started talking to you guys, I got up to 220.
Dr. Weiner:Up to 220.
Lacey:Yeah so that's great. It's pretty close. You gained back quite a bit of weight.
Deidre:Yeah, man, At that point seven or eight years out, it's just as difficult to lose weight as it was prior to having this.
Dr. Weiner:Yes, I agree. So you tried some nutritional modification and it wasn't going anywhere.
Joel:Yes, and I worked out like for a year straight. Yeah, you were really dedicated to working out I was doing really good, not like fake, working out like CrossFit.
Dr. Weiner:What do they get that f30?
Joel:I was in f45 a solid year and almost a year and a half and I was, and that's a brutal workout I felt like I was doing good, but I just wasn't seeing the?
Dr. Weiner:no, I wasn't seeing the weight loss right, it wasn't moving and I think that's something that people don't understand, which is that, oh, they think, oh, whenever someone chooses surgery, whenever someone chooses medications, it's because they're too lazy to do it on their own. That's not what it is it's that they've done all the things that they should be doing and it doesn't work right, and so that's what you were experiencing your nutrition was dialed in yeah your exercise was dialed in.
Joel:Yes, you'd regain the weight it was definitely very roller coaster at that time yeah, yeah I would get like peaks of like oh, I'm doing it.
Deidre:And then it come right back, yeah, and you probably see a little bit of weight loss and the weight regain. The weight loss and the weight regain, yeah.
Dr. Weiner:So just kind of little fluctuations around, but no substantial movement, none. So you're lucky enough to work at TMC, and so TMC is one of the few places in town that covers these medications reliably. Yes so when did you start and what medication did you start?
Joel:I started in 2002, 22. Okay.
Lacey:So I've been on medication for two years, okay.
Joel:And I started. The first one I started on was the daily.
Deidre:Sexenda, sexenda Right.
Joel:Yeah, that one was good for a little while.
Dr. Weiner:Yes, but I didn't how much did you lose on it?
Joel:I believe accurate. Accurately it was about 30 pounds okay, that's actually good.
Dr. Weiner:It's good for sex, endo yeah yeah about 15 you're a really good responder.
Deidre:Go away.
Joel:Loves the sleeve go away also this yeah meds but I think I was yeah, and I think it was just like it really, and I I think it helped having this sleeve prior to before, because I felt like the getting fuller faster like you did.
Deidre:There is a better response understanding my the brain
Joel:like because I that was a hard thing to learn when I first got the sleeve was knowing when to quit right but being on these afterwards, I learned how to. I remembered yeah you knew, I think there's two components to it.
Dr. Weiner:It's the behavioral memory from just learning. Hey, listen, I had a sleeve. You had to learn to slow down, to be more mindful. I think there's a physiologic memory too, where it kind of almost brings out some of those changes that the sleeve did, and there's just some synergy and we just keep seeing this over and over again.
Deidre:People have better responses on these medications after bariatric surgery than prior to bariatric surgery, people who haven't had bariatric surgery.
Joel:Your body remembers as well.
Dr. Weiner:Yeah, I mean there's just something about that set point that, even though you you know your set points started to go up when you're starting to regain the weight, your body still remembered that it used to be lower yeah, yeah um, and I think there's the medications.
Dr. Weiner:Kind of brings out that memory and I can't explain it any better than that, but I think, as we start digging through and we're putting that together in our own, in our own database, um, but that's what we're seeing over and over again is better response in patients who've had surgery.
Deidre:Yeah, so yeah, unfortunately you started sex, enda. I mean you started, you came to me, which you're the first person to come to me.
Dr. Weiner:That's awesome. You started with the OG, you founded the clinic.
Deidre:Excuse me, which is great you guys do like so much for us. I love to help everybody there. Um, so you started during the first big shortage of gp1 medications, yes, which was the first bogovie shortage, when it was on before zetbound came out, when it was on backward for an entire year, from january to december of 2022, the only thing that was available was sexenda, yeah, and so, even though it's not the best for weight loss, everybody had to start on sexenda during that time. It's all you could get, yeah yeah, so.
Dr. Weiner:So then you moved from sexenda to wigobi, to wigobi yes, and how'd you? How'd you manage the shortages?
Joel:um, I hadn't really noticed it too badly, like everyone else did my, I guess I stayed ahead of it and I yeah, planned yeah accordingly, but um, like just ordering, but I didn't really notice it. I've just now recently started noticing the shortage Like this now.
Dr. Weiner:So you're still on Wegovy.
Joel:I was on no, I switched to Zepbound for the last three months. About that, about three months I switched to Zepbound and now I can't find it.
Dr. Weiner:Yeah, right. So what dose of Wegovy were you on?
Joel:The max, the 2.4.
Dr. Weiner:And what dose is that bound?
Joel:Not the max. The 10 point, yeah, 10. Yeah.
Deidre:I consider that, like the comparable dose, there's never an exact correlation, but I usually say 2.4 and 10 is pretty much so.
Dr. Weiner:Deidre, when you have someone on Wegovi and you switch them over to Zep-Bound, you don't start at the bottom on Zep-Bound.
Deidre:No, because they're not going to get an effect because of the tolerance they've built up from being on previous GOP1s. Yeah, we go we're making that change.
Joel:Oh sorry, we're making that change from Wagobe to Zetbound. I didn't-. I thought it was very translative.
Lacey:I didn't notice it was very similar I did not notice any big change.
Joel:It had a lot of big side effects.
Dr. Weiner:Part of it's because you know as low as you're going to go.
Joel:I don't think I want to be any.
Dr. Weiner:Right, and so, as your weight gets closer to that kind of minimum that you're going to hit, the medications don't work. Like if you gave these medications to a relatively thin person, they're not going to lose 40 pounds. Yeah, and that's because it's not safe their body knows it's not safe to lose that kind of weight. Our body has some understanding of that and it lowers weights.
Deidre:both with surgery and with medication, people lose more gradually. They lose less weight because it's not safe to lose huge amounts of weight.
Joel:Yeah.
Dr. Weiner:That's what I like them also. I've been on it for two years, on a version of it for two years, and it's been a very slow and steady, gradual thing.
Joel:So why'd you switch from WeGoVie to?
Dr. Weiner:ZepBound Shortage, shortage yeah.
Deidre:So WeGoVie 2.4 is what's available now.
Dr. Weiner:Okay Right, zepbound is not and ZepBound is not Yep, yeah, zep, but it may be time to switch back to WeGoVie. So you're planning on staying on WeGoVie for the rest of your life?
Joel:I think so. I know that that was a suggestion that we had talked about before. I would like to be curious and taper off maybe one day and see if my body can handle it, but I also don't want to get back to where I was either.
Lacey:Right.
Joel:Back at my heaviest. I want to take advantage of where I was either. Right Back at my heaviest. I want to take advantage of science and help me, yeah.
Deidre:This is definitely the point where we start talking about maintenance dosing spacing the dosing out every other week, every third week, and that depends on your response to the medication. Some people are really hungry right at the end of the week and they need to take it every week. Some people can space it out and not experience too much extra hunger cravings, or lowering the dose so that you can take it weekly but become more of a maintenance dose. So there are lots of options actually. That way you're not losing as much, but you're, but you're also not taking the max dose forever.
Dr. Weiner:You split the difference right, okay, so you're leaning more towards some maintenance, dosing of this and and because I haven't been able because of the set balance shortage, and we'll go we just haven't been able to get it.
Joel:I think we had our consultation, our video thing about three weeks ago and I haven't been able to get it since then but. I've actually been doing okay. I've been okay, so I think now.
Deidre:Which is good. I mean that shows that you can go a few weeks without taking it, so that would be a good maintenance approach for you Right right and nothing crazy.
Dr. Weiner:And I'll tell you, I see this ability to tolerate these prolonged time periods without the medication more in bariatric surgery patients than I do in non-bariatric surgery yeah, interesting, yeah, definitely um, I haven't seen that as much in our patients who've lost, you know, 100 plus pounds, um with the weight, with the medication alone, without a history of surgery. I feel like when I see them they're gaining weight earlier.
Deidre:Right, you're seeing the same thing, deidre. I think so. Yeah, I definitely see in the bariatric patients more ability for you know, more sustainability. Yeah, or yeah, more ability to maintenance.
Joel:Must be that physiological memory.
Dr. Weiner:So what's it like being on we on week ovi and being married to the barbecue king how?
Lacey:does that all?
Dr. Weiner:work like. What do you? How are you handling that? How are you managing that? What are you doing with your diet now that you're on the meds?
Joel:that's tough.
Dr. Weiner:So that's really tough because especially summer time's coming around right and you guys are very social and you're always having parties.
Deidre:Always, okay, there's lots of good things you can eat that are barbecue foods proper nutrition that are good for you. Yes, beans, yes, even though they're a little higher in sugar sometimes. Yes, there's lots of lean meat choices. You don't have to sauce it up. You know greens.
Joel:Have you tried my husband's barbecue sauce? Just kidding, no, I was like.
Dr. Weiner:I mean, I love barbecue sauce, it turns out on salads. Yeah, what is going on?
Joel:Even on baked potatoes.
Dr. Weiner:Yep.
Joel:I'm from Missouri. We eat a lot of sauce. Yeah, I know I mean. It's all about portion control. That's the thing for me Absolutely. So he'll smoke chicken for me, or he'll smoke salmon for me and a lot of the smoked meats. It's like it doesn't really need much because it doesn't require a lot of seasoning. So it's very low sodium and stuff like that, because the flavor is all in the smoke. So it actually I feel like I've been doing okay.
Deidre:Turkey breast he does for me a lot. I smoke turkey breast.
Dr. Weiner:yes, and I just don't. Do you try to add a lot of vegetables to that?
Joel:Yes. I try, but I usually get full on the protein because it's so good.
Lacey:Yeah.
Dr. Weiner:But yeah, I should do that more. For sure, that's been kind of my. You know our nutritional strategy is based on a relatively small amount of animal protein and a lot of vegetables, right, yeah. And I think it's different for you too, because you know, in the rapid weight loss phase you were doing everything right. You were eating a lot of protein, you were focusing on protein, just like after surgery putting on protein.
Dr. Weiner:When you're losing weight on glp-1 meds, you should be eating a lot of protein and that should be your focus. But now that you're in your one, you know, at your weight you want and actually especially weaning off the meds and and a desire to kind of come off the meds to some degree. We have to change the nutritional strategy because you're not at risk for starvation, we're not worried about muscle loss because your weight is not changing, so you're not losing anything. And so that's where it comes time to kind of scale back on the animal protein and scale up on the vegetables and making that tradition from kind of protein to produce Plant-based proteins as well, increasing plant-based proteins.
Deidre:So you're still getting proteins. You're still getting, you know, complete proteins and 12 amino acids or 20 amino acids, but from plant sources, a variety of plant sources, and less from animal sources.
Dr. Weiner:But I think that's something that really hasn't gotten out there. It barely is getting out there. In bariatric surgery We've kind of you, you know, our nutritional plan, which is more plant-based than probably 98 of all bariatric surgery diets. Um is finally kind of starting to get catch some wind, where people are saying oh, I get it, I'm trying to maintain or lose weight, so maybe I should be eating more plants and less meat. And I think we need to see that same thing in the glp-1 meds and what you eat when you're in the weight loss phase and what you eat in the weight loss when you're stable very different, right, very different. And so now you're there, and so we need to give you the strategies to make sure that you're able to stay there. Thanks for being on the show.
Lacey:Yeah, thank you. Thank you for having me, absolutely.
Dr. Weiner:All right, so good to hear from Lacey. She really is just such a pleasure to work with.
Lacey:She's done such a great job.
Deidre:Yeah, it's been great.
Dr. Weiner:She's my second favorite assistant in the OR.
Deidre:She's very good.
Dr. Weiner:Deidre's first.
Deidre:But Lacey is really good. I'm okay with her stepping for me.
Dr. Weiner:Yeah, but Lacey's really, really a great assistant, yeah. So, deidre, what do you have for us for a nutrition segment?
Deidre:So today I wanted to talk about eating out after bariatric surgery. Okay, so I see this a lot because, especially since summertime is coming up, people are going on vacation and that means eating convenience foods, eating at restaurants. They have family coming to town, they're going on trips, and that can be really. People find that very daunting to navigate. You know, everybody kind of has this idea of if I'm at a restaurant I should be able to order what I want to eat, right, and if I'm on vacation I should get to eat all the great foods that I want to eat while I'm in this new place.
Deidre:But after pediatric surgery, not only will you not feel good if you eat those foods and same thing with GOP1 medications they work on the same pathway as pediatric surgery you will not feel good if you eat things high in carbs, fats and sugar, but you could be looking, you could cause weight gain, right, weight gain with that Sure. And so the way what I tell patients is, when you go out to eat, even at a fast food restaurant, you have to approach that meal just like you would approach a meal at home, right? You want to focus on lean proteins, fruits and vegetables, right? Produce every meal decrease. You know minimizing added fats. So, for instance, if you go to a restaurant, you know there's going to be an option that's a lean. That's either a fish dish without cream sauce, grilled preferably, or blackened right, not fried, not battered, or fried, not fried catfish or fish fry. Or there's going to be like a lean protein, like chicken or something like that, or even a lean beef is okay, you know, like a lean steak. And then, as your side choice, you're going to want to pick a vegetable and even a salad, although salads can be have a lot of hidden things in them. When you pick salad, you have to really be careful to. You know dressing on the side, preferably a light dressing if they have it, or oil and vinegar is even better. And then also the added toppings, like you want. You know no cheese. You know no bacon bits. Like you have to be careful with stuff like that, right, those can add a lot of hidden calories. The same thing you go to a fast food restaurant.
Deidre:Almost all fast food restaurant menus have at least a salad or a chicken sandwich. You know you can say you know no bread or no mayonnaise. Or for salads, you know you look for like a house salad type salad. Don't get something like a ca Caesar salad that's laden high fat dressing and cheese. You want to look for kind of the most whole food choice. And then even a place like Taco Bell, which is one of my favorite fast food restaurants.
Deidre:You can get the fresca menu, get chicken. You know fresca tacos and eat the chicken and tomatoes and you know pico. Out of the inside, I mean, they also have like two different types like a black bean and a pinto bean bowl with cheese on top. You know they also have some whole food protein bowls. So there's a lot of options out there. So the first thing you can do to help prepare is to look at menus ahead of time. You know what fast food restaurants are around you. You know what you like to go to for lunch and what your office likes to go to. Look at those menus, look at the calories, look at the ingredients and use the same rules whole foods, lean proteins, lots of produce, every meal that you would use at home.
Dr. Weiner:Zoe talks a lot about the planned indulgences, and I think that's something we all support is that you don't have to be perfect 100% of the time, but if you eat out regularly, then you have to eat well when you eat out. If you eat out once a month, then you can use that as one of your planned indulgences, so the frequency really matters there. All right, so why don't we move into our questions from social media? Hawel, why don't you start us off with our first question?
Lacey:All right. So the first question is from Jennifer. I was a patient of Dr Weiner's in Michigan. I have a question. I am nine years post-op from a sleeve. My sugar levels have recently gone up so my doctor put me on Trulicity. I've heard of some patients damaging their vagus nerve and their stomach stops working. How possible is this scenario and should I worry about it, being a bariatric patient?
Dr. Weiner:So, first of all, deidre, what do you think about trulicity?
Deidre:You prescribe more of these meds than I do, truthfully, yeah trulicity is kind of a low end of weight loss when it comes to GOP1 medications. Yes, it will help control your blood sugar, also on the low end for that as well. You know Victoza and trulicity are about 6% to 10% weight loss. The only thing that makes trulicity slightly preferable to victosa is that it's a weekly injection instead of daily and there's one more dose range than with victosa. But really they're older medications, they're not very effective. Ozempic and monjar are much more effective for for glycemic control and you know, conversely, we'll go vn. Is that bound for weight loss?
Deidre:right, so um, yeah, trulicity not great weight unfortunately for a lot patients, that's the only coverage they have, and so it's better than nothing. It's probably the cheapest GLP-1.
Dr. Weiner:That would be my guess. That and Victoza the cheap ones?
Lacey:Yeah, absolutely.
Dr. Weiner:So first of all, the vagus nerve. So the vagus nerve is, you know what vagus means in Latin Latin, wanderer, and that's because the nerve, it starts up in your neck and it goes down the esophagus. We see it all the time when we do hiatal hernia repairs and once it goes there it goes onto the stomach and it goes just all over the place and it really spreads over almost your entire body. So the first is GLP-1s. Actually, if anything, preserve nerves, because nerve damage is neuropathy and we see that as a consequence of diabetes. So when we bring people's sugar under control, we see improvement of neuropathy.
Deidre:That's why people experience gastroparesis with diabetes Right.
Dr. Weiner:So the truth is, if you have diabetes and you have gastroparesis, like Deidre just mentioned, and you get on these medications and your sugar improves, you're actually going to get improvement in vagus nerve functioning. And so, no, there's absolutely no truth to these medications injuring the vagus nerve. Now, ileus is a different situation and we see that quite frequently, right, I mean, people get an ileus after this surgery To some degree. The intent of these medications is that they slow down, initially, gastric emptying, but it's not that selective that it only works on the stomach, it works on the small intestine, it works on the colon. That's why we see constipation. So it slows down all of your gastrointestinal motility.
Dr. Weiner:But it's really important that this is a side effect of the medication, not a damage that it causes Right and so when you stop taking the medication, the motility returns back to normal Right and so there's zero evidence that this causes any permanent gastroparesis, permanent intestinal paralysis. It causes temporary paralysis, temporary ileus while you're taking it. So, no, I don't think you should have any risk. My concern is that you're not going to lose much weight because you're using TruLicity instead of one of the better meds.
Deidre:Right, but she may not have coverage for one of the medications. She may not have coverage.
Dr. Weiner:She may not have coverage, but she's in Michigan, I bet she does. Coverage is so much better in. They're one of the states where Medicaid covers. Yes, they are they cover Bagovi Yep, yep, all right. So what's our next question?
Lacey:Hoel, what do you got? The next question comes from YouTube, from Lily. I had a sleeve last year and I am one year and one month post-op. I only lost 45 pounds from 270 pounds to 225. I wish to be 185. I 270 pounds to 225. I wish to be 185. I started Ozempic at 220 pounds. I am thinking of getting the bypass or duodenal switch and I am not sure if it's a good idea.
Dr. Weiner:All right, so no response to Ozempic. What do you think, deidre?
Deidre:Well, there could be a few things going on there. Um one, she could just be not a great responder. She wasn't a good responder to bariatric surgery either, and they do work on the same pathway, uh, in a sense. Um two, she might want to look at nutrition. Is she eating the right things? Is she being active? Three, ozempic is very dose dependent. You know where she is she is. Does she need to be at a higher dose? Does she need to be?
Lacey:does she reach the max dose?
Deidre:You know. So there are, there are some. There are some things we could definitely investigate. Also, what are the medications that she's on? Is she on other medications that could be affecting her weight?
Dr. Weiner:Here's what I see a lot. I'm sure you see this too. Oh, I took Ozempic and it didn't work. Well, talk to me, let's walk through. What did you take? Oh, I did the starter dose. How much was the starter dose? 0.25. Right.
Deidre:Well, it's not magic. How?
Dr. Weiner:long did you take it? I took it for four weeks. Right and how much weight did you lose? I didn't lose any weight. That's not shocking, especially in diabetics.
Deidre:Diabetics never lose weight on the 0.25. Any of the big comorbid, they're all going to lose weight more slowly.
Dr. Weiner:So you know. The question I have is what dose did you try? Did you get all the way to the two milligram dose of Ozempic? You know Wegovy's 2.4. The highest dose of Ozempic's. Two pretty close. And so until someone has kind of hit that max dose, I'd say if you're not losing weight on one, you're probably not going to lose weight.
Deidre:Yeah, you're probably not going to respond to that medication. That doesn't mean you're not going to be good responders to other GOP1s, though I definitely see people who are good responders to Zepan, which is Monjaro, that were not good responders on Magovi and Ozempic.
Dr. Weiner:So you know, our take on sleeve regain is you really want to explore the meds fully before you move on to revision, and so my question you know for Lily is have you fully explored Ozempic? Have you gone up to that highest two milligram dose? Do you have coverage for Zepfound or Monjaro? Can we switch you over to that medication and see if you also don't respond to that medication and at that point I would then we're still not seeing a response because we see about 15% of people not respond to these meds.
Deidre:Yeah, no, it's definitely out there. It's out there, yeah.
Dr. Weiner:So if they're not, if we've really gone through all of the doses and done a very thorough eval, and again, that's where it might be worth talking to an obesity specialist, someone who prescribes these things all day long and really has a good understanding, knows the dosing, knows side effects, knows how you should be eating, can review your medications and knows all of the components of weight loss and these medications, to make these medications effective.
Dr. Weiner:Yeah, we see 15% of people really not respond to these meds. We probably see a similar number are the super responders.
Deidre:They can pretty much eat cheeseburgers and they still get thin and lose weight. They can be on a super low dose of medication and lose 105, you know, 50 pounds.
Dr. Weiner:Yeah, we saw the same thing in bariatric surgery. We see 15% of our patients just unbelievable response. But the remaining 70% of people are going to fall somewhere in between there, right, and that's where the nutrition comes in. The exercise comes in the lifestyle, the proper dosing, and in that group of people there's going to be a right way and a wrong way to do this. And we just see time and time again that this is being done suboptimally.
Deidre:Right. Well, people just don't have the experience. A lot of providers don't prescribe these as their main job, as their main job. Right, that's what we do, and so they don't have the experience needed to know how to optimize the medications for weight loss.
Dr. Weiner:So I think that would be the thing I'd want to explore with Lily. All right, so what's our final question here, howell?
Lacey:The final question came via email from Chris. Can you share your thoughts on the product label statement? Discontinue Ozempic in women at least two months before a planned pregnancy.
Dr. Weiner:Yeah, so, wow, there's a lot here, huh.
Deidre:Yeah, we were talking about this earlier.
Dr. Weiner:So, deidre, how do you counsel patients of childbearing age with a goal of becoming pregnant who are taking GLP-1s?
Deidre:Well, I mean double protection, right? So something like an IUD or, if you're on control, of barrier protection as well, and then we counsel them to stop it two months before surgery, because that's what the package insert says. But I have had a couple of patients that did not realize they were pregnant because you don't usually realize you're pregnant for four or eight weeks, and so it didn't stop. The medications they haven't been studied, so we don't know if there's going to be any long-term consequences of that.
Dr. Weiner:There's some concern. I mean there's some data registries out there, so Eli Lilly is putting together a data registry, but there are some concerns about the safety in pregnancy.
Deidre:Yeah, and I think until we know for sure.
Dr. Weiner:Definitely we want to avoid that For sure you cannot take it after you become pregnant or breastfeeding at all. I think it's important also to state that it's not that we don't have any evidence of safety. It's that there's a few studies very small, very nonspecific, and all in diabetics. So all of the data that's out there is only in diabetic patients, who have higher risks of birth defects and pregnancy issues. But there is some evidence that may point to this not being safe in pregnancy and I think that's really important. We have to start from that assumption.
Dr. Weiner:It's very tempting to say, well, we want it to be safe in pregnancy because it saves us from so many problems, but I don't know that we can actually say that, because it's a huge problem. If you've lost 60 or 70 pounds on these meds and then you stop taking them and become pregnant, you can gain 40 pounds in that first trimester, which is extremely dangerous for the baby and the mother as well, and so those rapid shifts in weight that we could see, it's kind of a perfect storm. You stop the GLP-1 and you become pregnant and we can see massive weight gain in that situation.
Dr. Weiner:And that's one question I still don't have an answer to we have zero guidelines. I think we're going to see more and more people talking about this.
Deidre:Well as fertility increases when you lose weight on these medications. Yes, right.
Dr. Weiner:Yeah, exactly, especially as people start using this as a bridge to fertility, right? I mean, if a fertility medicine increased your risk of becoming pregnant but also increased your risk of birth defects, that would be a very controversial medication, right? Yeah, and so that may be what we have in these meds. We cannot say for certain that we don't have that, and so I think, for those of you who are considering pregnancy and considering using these meds with fertility, I would tread very carefully through this territory. I would make sure you're working with a very knowledgeable OB and walking through this as you're planning and heading toward pregnancy, as opposed to kind of limping into it and becoming pregnant, because we don't know the answer. Again, there is not data that shows that it's dangerous, right, but there is some suspicion that there could be some issues with that Right Interesting, and I don't know that we be some issues with that Right.
Dr. Weiner:Interesting and I don't know that we we don't know it for sure we don't know the answer yet, and without question. Because of that, we must assume that it is unsafe and we have to proceed as if that is the truth until we have more data. Otherwise, so this is really interesting. We're going to see this. I'm sure we're going to talk about this again, probably.
Deidre:Yeah, it's a very, very challenging subject and you know, my heart goes out to women of childbearing age kind of using this. As for fertility, because what do you do? I mean, it's really, it's a whole. It's actually very interesting because we've been using bariatric surgery for fertility for a long time and there's not really much increased risk with pregnancy with bariatric surgery. So you can lose weight with bariatric surgery, get pregnant without risk and very little risk to the pregnancy itself. We definitely know how to manage it very effectively. Um, very little risk of the fetus. But with these uop1s and more people are going to be using these for weight loss instead of surgery there's this unknown and for fertility instead of surgery there's this unknown, you know. And yeah, it makes it a lot more complicated.
Dr. Weiner:Yep for sure. All right, we don't have all the answers on the show, huh, nope, okay, well, thank you. This podcast is produced by Sierra Miller and Rhiannon Griffin and the editing is done by AutoGrow. I want to give a special thanks to our guest Lacey. Please check us out on social media or our website. Consider joining our online nutrition program or our Pound to Cure Platinum program for those people seeking really customized personal assistance for management of weight regain after bariatric surgery or GLP-1 use. We'll see you next time. Thanks,