Will Ozempic Make You Go Blind?

Episode 34 of The Pound of Cure Weight Loss Podcast is titled, Will Ozempic Make You Go Blind? The title comes from our In the News segment, where we cover an article from The Hill titled, Ozempic/Wegovy May be Linked to Rare Form of Blindness. If you’re taking this medication, this is probably a very scary headline. And, of course, it’s meant to be so that you click through. So, what is the science behind the headline? Tune in to find out!
 
We are very excited to bring you this week’s Patient Story segment because we are talking to Dave. You may know him as The Man on Mounjaro or from his podcast, On the Pen. I’ve talked about him, previously, on the podcast because he is a fountain of knowledge on all the weight loss medications in the pipeline. He is going to share his story with you and offer a 1, 3, and 5-year outlook on the future of obesity medications.
 
In our Nutrition segment, Zoe dives deeper into vegan health halo’s. Some stores are especially good at marketing and packaging products to make them appear healthy. But in reality, they are just as processed and sugary as their non-vegan counterparts.
 
Finally, we answer 3 of our listeners questions including, alcohol intake after a gastric bypass, tips for fixing your metabolism while recovering from Anorexia, and what to do if you miss a dose of Ozempic. 
 
If you enjoy listening to the podcast every week, please leave us a review on your favorite listening platform. If you have a question that you'd like for us to answer on the podcast, please reach out to us through social media (Instagram, TikTok, Facebook or YouTube), or the website.

Transcript

Dr. Weiner: 0:17

There's a really important philosophy in medicine, which is that correlation does not prove causation, which means, just because two things happen at the same time doesn't mean that the first thing caused the second thing.

Zoe: 0:35

All right, welcome back to the Pound of Cure. Weight Loss Podcast, episode 34. Will Ozempic make you blind? Yeah, we're going to find out that would be pretty bad if it did A lot of people being yeah, yeah.

Dr. Weiner: 0:51

But there's definitely something that we a study we have to talk about. But anyway, before we get to that, zoe, our patient story. He's actually not one of our own patients. I met him on TikTok. Well, actually, no, shanil was the first person that I ever met on TikTok, and Dave is the second one. Shanil is awesome, so my first experience of meeting people on.

Zoe: 1:12

TikTok was great, set the bar high.

Dr. Weiner: 1:13

Set the bar high. We'll see what Dave has to say. I think it's going to be really interesting. Have you met people on TikTok?

Zoe: 1:21

No, but I definitely have to be very mindful of my TikTok time because it is very rabbit hole-ish.

Dr. Weiner: 1:28

It's amazing how it just sucks you in, sucks you in. I mean it's terrible, I don't know. I wish Albert Einstein was alive because he could talk about how, like once you get into TikTok, like time just compresses and like literally five minutes goes by like it's 30 seconds.

Zoe: 1:46

Yeah, I was hearing something that was kind of more so talking about the like. Obviously, we all know attention spans are short, but it's also that kind of that dopamine response that when you're watching a show, for example, or a YouTube video, something that's a little longer, that when you're watching a show, for example, or a YouTube video, something that's a little longer, I feel like I'm messing it up. But ultimately it's a more delayed gratification and it holds you for that longer kind of payoff. But the reason why TikTok can really suck you in so much is because you're chasing that.

Dr. Weiner: 2:20

Hit that, hit that, hit that next little bit like oh wow, look at that. Oh, my god, you know that little bit of surprise or entertainment. Um, yeah, I mean, you know I'm a surgeon, so I'm a expert at delayed gratification. You know I didn't start earning money until I was in my literally mid-30s, um, and generally most people who go into a fairly, um, training intensive field, uh, specialize in delayed gratification. So I've been a little bit late to the party with TikTok, but it's there for sure, it's there.

Dr. Weiner: 2:49

And honestly, I don't know, it doesn't work that well for me because I can't say anything. I can't tell someone what my name is in under 60 seconds. I just keep talking and talking, and talking. So, anyway, well, we're going to hear from Dave and I think he's going to have some interesting things, but before we get to him, let's talk about our In the News segment. So this is where our title comes from, about Ozempic making you blind, and it comes from the Hill and it really is referencing a study in JAMA, which is the Journal of the American Medical Association, which is a pretty reputable journal. But then what they have is all these little specialty journals, and so if you get something in the real JAMA, that's like a big deal, but getting it in the specialty journal that's much less of a big deal. So this is in one of the specialty journals, so I don't want people thinking this is like New England Journal of Medicine, blockbuster incredibly powerful, well-done study. It's not that. It's definitely not that.

Dr. Weiner: 3:45

So they looked at a disease called non-arteritic ischemia, optic neuropathy, or NAION or NION disease, and they looked at a huge sample of patients and they found 194 diabetic patients type 2 diabetes patients who were taking semaglutide ozempic for treatment of their diabetes, and they found that 17 eventually developed this NION. And NION is a disease where essentially, the blood supply to the optic nerve is compromised and you can lose sight. Now, full blindness is fairly uncommon with this condition, but you can definitely lose sight and it's irreversible. Once you get it, it generally doesn't get worse, but it doesn't get better either. And so they found 17 people which was four times higher than they would have expected developed this condition. And then they looked at people who were taking semaglutide for obesity and they found 20 people out of I think it was 380 people developed Nyon, which is eight times higher than the baseline rate. So both in diabetics and in non-diabetics those taking semaglutide now this was not Zepbound or Trizepatide.

Dr. Weiner: 5:03

We don't know if it is something unique to semaglutide or is it all GLP-1s, and we actually don't know if it's real, and so this is an observational study. So observational studies mean that, hey, we saw this, we noticed this. It doesn't prove causation, and there's a really important philosophy in medicine, which is that correlation does not prove causation, which means just because two things happen at the same time doesn't mean that the first thing caused the second thing, and so there's absolutely no evidence from this study that shows that semaglutide does cause this NIA. Now, it doesn't mean it doesn't either, and so what they need to do is more randomized controlled trials and maybe looking at some of the original trials that they ran for both diabetes and for obesity. So let's just say there's a four times increase, or even an eight times increase in the development of Nyon, does that mean we should stop prescribing semaglutide altogether?

Dr. Weiner: 6:13

I think if we can show that we don't see it in other drugs, I think that's going to be a big hit for semaglutide, and I think one thing about that's going to be really important for the access to care and the affordability is the more drugs there are, the more access, the more affordability.

Dr. Weiner: 6:28

The more we have multiple companies competing for business, the better. So to me, if it was just one drug that kind of got pushed out because of a side effect, that would probably be bad for everybody's access. But the truth is, nion is a relatively rare condition, and so even with an eight times increase, that would mean that there's about 70 out of 100,000 people who lose sight. But keep in mind, if we're looking at a 20 to 25% cardiovascular risk reduction, that's 20 to 25,000 out of 100,000 people who don't have a cardiovascular event, and so you can't necessarily look at one thing like this. We know NSAIDs, advil, aleve, ibuprofen which most people take like it's no big deal, causes Stevens-Johnson syndrome, which can be a terrible, terrible awful condition where essentially your skin falls off, and with everything with antibiotics, we see anaphylaxis. With a lot of these medications that we take commonly, there's these very rare uncommon events and we accept them.

Zoe: 7:38

Small percentage.

Dr. Weiner: 7:38

Yeah, small percentage. So my suspicion is, my hunch is, they may find something here. This might be real, and I think one of the reasons it might be real is they saw it in the diabetics and the non-diabetics and so they saw it in two different groups and that also suggests that there may be something there. But I think, even if they do, and especially if it's just a decrease in your vision, vision loss, not going blind then my hunch is it's not going to change our prescribing recommendations, it's not going to change much about this.

Zoe: 8:15

This is just like one of those risks that the patient is aware of when they start, that the patient is aware of when they start, and weighing that risk versus reward, like is this tiny percentage of potentially developing this disease, you know, worth not living the quality of life that they desire? That the medication can provide.

Dr. Weiner: 8:33

Yeah, I mean, I think you know we can see how much these meds change people's lives. The other thing I would say is we're gonna find more stuff like this. Right, this is the first thing we're seeing. There's going to be more. These drugs are super powerful. There's going to be some bad things about them. Not only that, but this study, this little JAMA ophthalmology observation study that probably I don't know the details of the article, but how much time they put into this, but this could have been 30 or 40 hours of someone's time to write this article. Not exactly like what we see with some trials where it's like years and years with many people involved. This was a relatively small trial and it's going to hit the news cycle big time.

Zoe: 9:20

Well, I wanted to say so. Like you mentioned, this is an observational study which shows, okay, this could be correlated, not caused by one, you know, it's not a causation, but this is a great example of where news places get clickbait or where something can be really blown out of proportion because they take this oh, let me grab this little snippet, turn it into this thing, and then all we see or, you know, all you see is the headline of GLP-1 causes blindness and, without getting into the details of the study, okay, yeah, now we dig a little deeper, and I think that's what's really important about, you know, our in the news segment is that we're able to dig through this and help our listeners be a little bit more astute to. Okay, let me not necessarily fall for these super clickbaity type titles yeah, well, we did use that title for our podcast.

Dr. Weiner: 10:22

Well, hopefully it worked.

Zoe: 10:25

Hopefully it worked so that you can get some reasonable information, Real information right that this is not a reason to stop taking your semaglutide.

Dr. Weiner: 10:29

Exactly, this is not the end of WeGoV and Ozempic. This is an observational study that needs a lot more work before we arrive to any conclusions. Yeah, so let's move on to our patient story. Let's bring on the man on Monjaro, dave.

Zoe: 10:45

All right, Well, welcome Dave. Welcome to the show. Super excited to have you here.

Dave: 10:51

I'm super excited to be here. I really appreciate it. It's not that often that I get the opportunity to go somewhere else and, you know, to somebody else's platform and have a conversation, so I love being on the other side of this. Thank you so much for having me Absolutely.

Dr. Weiner: 11:54

Why don't you, why don't you tell us your story? You know how did you become man on on Monjaro, like, how did this all start, first as a patient and then kind of as on social media?

Dave: 12:05

Sure, it's really, it's really become a whole deal, right? And when I talk to people in real life, the people who are, who are, you know, trying to understand what is it that you're doing on social media? Because not that many people in my real life are that tuned into what we talk about, but it's I just I'm always like it's it's become this whole deal. But basically, about 2021, I was given a really sudden and unexpected diagnosis of type 2 diabetes and you know, you might look at that and you say this guy's been overweight for most of his adult life, he's approaching 40 years old. It's not that uncommon.

Dave: 12:42

But you know, what's interesting to me is that I yo-yoed on ketogenic diets for 20 years. So if you pull out, maybe three to four months out of every year for the last 20 years, on average I was on some sort of low carb or ketogenic diet. It's just that the crash. So I always say that I would lose 25 pounds and I gained back 30, 35 pounds, and so I was on this roller coaster for about 20 years the better part of 20 years and in 2021, received that type two diabetes diagnosis and my doctor was just like what do you want to do. What do you want to do? It's time for some mid-course corrections and I said well, I'll tell you what I don't want to do.

Dave: 13:21

I don't want to take medicine and he's like great, we'll put you on a ketogenic diet, we'll get your weight down, we'll get your A1C down, and I was like I'm willing to do whatever you want me to do because you're a lot smarter than I am, but I need you to know that I've I've. I understand keto, I understand the science behind it and I've yo-yo. I have never been able to sustain it. He's like well, if you want to keep your diabetes down, you'll do it. And so I'm thinking, you know, rattling around in my brain are my four children. I have four children ages four all the way up to 10 years old now, and I'm just thinking about being around for them.

Dave: 14:00

My own father died at 54 years old from a massive heart attack, and I just don't want the same for my own children, and so I embarked on a year of really strict keto. By the book, I was wearing the CGM that. I'm sure you do the same thing. My doctor could see what was going on there. I had a ketone monitor that was reporting to him as well, and so he knew that I was following the rules. My A1C a year into it was great non-diabetic numbers, but my weight had gone from 319 pounds to 312 pounds in a full year of white knuckle keto, and so you know I was sort of at the end of my rope. I was like this is what I was afraid was going to happen. And he said well, you're one of maybe five out of the nearly thousand people that have been through my program that just don't respond from a weight loss standpoint with keto. You're probably a candidate for bariatric surgery.

Dave: 14:57

Now, at that time, you know, I'm 38 years old and and I'm looking at that and I'm saying I don't really want to go through bariatric surgery at my age, but I I don't want to not be around for my kids either. So it was sort of like one of those. It was sort of a hard pill for me to swallow in that initial consultation because in my mind and I realized this is incorrect thinking, but in my mind bariatric surgery was for people who were severely overweight, you know, three, four, 500 pounds overweight, and I never considered myself even a candidate. But the more we talked I was on board, I was ready to do it, but I didn't have insurance coverage. And he said well, dave, the good news, bad news is there's a real great class of medications out there called GLP ones. They're basically accomplished, accomplishing hormonally what some bariatric surgery is able to accomplish for people and you're going to be able to get it because you're diabetic and I was like great to accomplish for people and you're going to be able to get it because you're diabetic, and I was like great.

Dave: 15:56

So that set me off on this path to learn more about the medications. And I came to YouTube and there was a real deficit of information from the patient perspective. Lots of I lost a hundred pounds or I lost 150 pounds on Ozepic, but nobody really sharing. Yeah, but this is what I've learned about the medication. This is how they, this is what it's like to actually take the medication, and so that was really the start of something that really morphed into. Just as I learn stuff, I like to share it and that's that's really the heart of On the Pen. Yeah.

Dr. Weiner: 16:21

Huh, Fantastic. So you never had bariatric surgery. So you started on Monjaro I'm assuming by your, your name, and and have you been successful with your weight loss efforts?

Dave: 16:32

your name and have you been successful with your weight loss efforts? So it's been a really disjointed journey on the pen, so to speak. So I started on Manjaro and, like many people, I was affected by the shortages.

Dave: 16:44

And this was back at the end of 2022 into early 2023. So for those of us who have been on the pen for a while, the shortages are nothing new, right? I know a lot of people are just experiencing it now, getting on Zetbound and Wicovi for weight loss. But I blew through the doses, right? My doctor was like hey, this is what the clinical trials say. People do the best on 15. We'll get you up to 15. Well, I couldn't get a lot of the middle doses and I tolerated it from a side effect standpoint really well. So within three months I was to 15 milligrams, Okay.

Dave: 17:14

That's fast so a really fast titration process and probably within the first six months I was down about 10% of my body weight. That's good, which was pretty good I mean pretty fast. But then I started getting really debilitating migraines.

Sierra: 17:29

And so.

Dave: 17:29

I backed off on the dose, backed off on the dose, and so I really ended up starting over and really, as I titrated back up and got up to 15 milligrams again, it just didn't have the oomph that it once did and I would say, both from a glucose control standpoint and a appetite suppression sort of standpoint, it just didn't do what it did. So I actually did three months at the beginning of this calendar year, 2024. I actually went on Ozepic for for three months just to see if I would respond better to semaglutide. Anecdotally, I'd heard from enough people that you know it worked better for them.

Dave: 18:05

You know, not most people, but some, and so maybe I'm some and so I took that and I maintained my weight but I had gained back. In that, you know, sort of titrating down and back up, I had gained back about 15 pounds and so as I sit here today, I'm at about 292, which, from you know, my starting weight on this journey before uh Manjaro was 219. So you know, a pretty, I mean it's, it's, you know, 20, some pounds or whatever. But it's not where I want to be for sure it's.

Dr. Weiner: 18:36

I mean, first of all, you had diabetes, right, so diabetics lose less weight on these meds. And then I think you know, if you look at the surmount trial, there's one, you know. I don't think people talk about this graph enough, but I go over it with all my patients but it maps out at the three doses and I think that's another important thing in terms of access to care but it maps out the percent of people who lose greater than 5% of their total body weight and the percent who lose greater than 10%. It goes all the way up to 25% and what you see is about 10% of people lose less than 5% of their total body weight. You move up to 10% and this is in non-diabetics. You move up to-.

Dave: 19:18

In a very controlled study right, A controlled diet, controlled movement.

Dr. Weiner: 19:24

So we get up to 10%, and I don't know the number offhand, but it's like 20%, 25%, somewhere in that range. It's a very real percent of people who lose less than 10% of their total body weight. I think there's something that and, again, social media is partly to blame because the algorithm is going to either pump up all the people who are puking their guts out and totally miserable, or it's going to pump up the people who have lost 150 pounds. The truth is, then the but the truth is, for 95% of people, they're going to be somewhere in between those two places and, and, and that's what we're we're seeing, and so I think, in all honesty, your, your response is not, definitely not the worst I've ever seen on these meds, and and you know, I think it just shows the complexity of these medications that there's real, there's a lot of nuance and a lot to them. What have you done with nutrition while on these meds? Have you put a lot of energy into nutrition? Are you still kind of on the keto plan?

Dave: 20:31

that's the question I get answered, get asked the most right, because I've been making videos for a year and a half now and people will see those videos. I saw your video from a year ago. I see your video from now. It doesn't look like you've lost any weight. And so the reality is what I used to say when I first started Majara, and this was this got me down to that. You know, 30, 35, 36 pounds down right.

Dave: 20:48

This was my approach initially is I had white knuckled it for so long, including that, that again, remembering back to the prior year before starting Manjaro, that was a white knuckling the ketogenic diet. I was so over that roller coaster, that 20 year roller coaster, that I kind of mentally just said to myself I'm just going to eat and I'm going to let my body do the, do the feedback, right, I'll eat when I'm hungry, I won't eat when I'm not hungry. And the medicine allowed me to do that. And to the to the point where I said, said earlier, I was on that initial titration up down about 10% of my body weight, and it for sure was just calorie restriction.

Dave: 21:32

But it wasn't intentional calorie restriction. I was just committed to not going on a yo-yo I was committed to. I'm going to eat the way that I know I can eat for the next 30 years of my life and sustain it, and it was fine until it wasn't right. And so since sort of like pulling back on the dose and the scale started going up, I've gone back and forth between different things, really just sort of fumbling my way through it. So that's one of those areas where people will ask me on my channel what should I eat on this medication?

Dave: 22:03

Like that's not the type of content that I make is I'm trying to figure that out for myself, and also the disease of diabetes and the disease of obesity are so nuanced, and so I mean just the spectrum of experiences people can have with those diseases. I think that it would be irresponsible for me to give that kind of feedback to people who are asking me on my channel. I realize that's probably not a great answer, but it is the answer.

Zoe: 22:29

But it's the real answer. I did want to ask you did you notice, while you were kind of experiencing the height of the benefit from when you first started on Manjaro, a change in the foods you were craving? Obviously, you were able to eat less, but what I noticed with a lot of patients is that they start craving different types of food, maybe more nutritious type foods. Did you actually find that at all?

Dave: 22:56

Never. Uh so, and and I I will just echo and validate what you're saying with my own experience. That is what I hear from the majority of people who comment on videos that I make are in our On the Pen community. I used to eat sugar. Now I want leafy greens. I used to. I mean, it is beyond even the food conversation. I used to gamble. I used to go to the casino three times a week.

Sierra: 23:23

I don't want to go there anymore.

Dave: 23:25

And so you'll hear, I hear this, but my taste buds never changed and I realized there's even data coming out that shows that that is actually happening with semaglutide, especially in response to sugar. But for me, none of that really ever changed. I still desired the same amount of food. It's just that I was satiated much quicker.

Dr. Weiner: 23:49

So so I would let me just throw something out there, just kind of spitballing some ideas the, the program, the nutritional program that we recommend it really, you know, and one thing that to me has been really cool about Temaglutide and glp-1 meds is that they work the same way bariatric surgery does, just like your doc mentioned that they they cause this hormonal shift and they cause this weight loss, and so what?

Dr. Weiner: 24:15

What I first noticed very early on in my practice was that my gastric bypass patients, my post bariatric surgery patients, were saying all the things that you're hearing about leafy greens and not eating sugar and all those dietary changes. I started to kind of listen to what types of foods they were eating, and that's where our nutritional plan comes from. So you talk about keto, you talk about calorie restriction. What if there's another way of eating that you haven't considered? And I think, when I'm kind of hearing your story, a lot of the kind of modest weight loss that you've experienced I think is from your diabetes. Diabetes causes much less weight loss with these meds and if we could kind of focus on reducing your diabetes with food. And I know you did have a decent response to the ketogenic diet, but the problem is there's so much animal fat.

Zoe: 25:06

But also nobody wants to do that forever.

Dr. Weiner: 25:08

Nobody wants to do it forever too. But there's so much animal fat in that, and animal fat does worsen your insulin resistance too, and so you get this like push pull effect, where on one hand, you're just not eating any carbohydrates, so the sugars are going down, but on the other hand, you're eating a lot of animal fat, and so your insulin resistance is getting worse, and the triglycerides.

Dave: 25:38

That's very interesting that you mentioned it because, um, about about a year into my journey with that ketogenic diet, um, I couldn't be able to tell you what the name of the test was, but it was a test that measures your fasting insulin levels, right, right. The unit of measure that they used was weird and I didn't understand it the way that the report read, but I will say it was. There was very little difference in my insulin level numbers after a year on keto than there was initially. My A1C was down, but my insulin levels were not off the charts, right. And that was one question that I had that I never got a good answer to is like, well, I'm doing what I'm supposed to do, why are my insulin levels still that high?

Dr. Weiner: 26:19

Because it's very interesting. Yeah, you're gaming the system. You're just not eating the carbs, and so you're preventing the blood sugar spikes, but you're not fixing the underlying problem, which is the insulin resistance. And the GLP-1s help, but sometimes the diabetes gets in the way of that, and that's where you really have to bring the food in, and that's what our whole nutrition program is founded on. That's what zoe does all day long is counsel patients on eating on glp-1 meds, and we try to promote a produce heavy diet, not necessarily a vegan diet, but a produce heavy diet, because those phytonutrients you find in the fruits and the vegetables and, um, you know are so are so valuable, uh, for reducing your insulin resistance.

Dave: 27:06

Interesting yeah.

Dr. Weiner: 27:08

Well, anyway, let's move on, because I think there's so much more to talk about and I really want to pick your brain on some of these topics, because you've just spent so much time and energy on putting these in. So I've got a couple of questions I want to hear. Here are your thoughts on you know, you and I share a real passion for access to these medications, affordability, and I think we both kind of see the future of what's going to happen with these meds and they're going to get better and they're going to get less expensive and they're going to become a huge part of our society. So my first question is what do you think the GLP-1 world looks like at one year, three years and five years out? Yeah, there's some important things coming down the pipeline, so what do you see there?

Dave: 27:55

Well, first of all, to Rob, from a friend of mine, sina, who runs Join Fridays, he always says the future is bright, and so I got to steal that from him. The future is bright when it comes to sort of like all the aspects you could talk about in the landscape of GLP-1s, whether it's accessibility, whether it's medicines that are better, more powerful or provide maybe a higher quality of weight loss. So it depends on which track you want to talk there. But I think the biggest track that I talk in terms of is into my community is accessibility, because that's ultimately the battles I think that most are fighting right now. That because most people that I interact with respond really well to these medications, these current, the current class of medications, strictly from a weight loss standpoint, which I think is why most people get into this. They don't get into it to get fixed metabolically. That is a a real upside that people don't. But you know, I think most people go. I want to lose weight and this medicine is going to help me. Um, I think in the process, hopefully they're learning more about why and what is actually getting corrected in their body. But so from a strict weight loss standpoint, it seems to work really well for people. It's just the accessibility right now is just absolutely atrocious, and so I think in one year from now, I think it's going to be a bit bumpy, right, so one year takes us to July of 2025, right, we still don't have another generation of drugs out yet, so we're still dealing with terzepatide and semaglutide Now. We will have higher doses of those drugs by then. Probably. We're expecting 50 milligram Rebelsis yet this year, higher doses of semaglutide and, you know, higher doses of terzapatide, hopefully around that time. So higher dose is great, but really more demand and not enough capacity to keep up with it.

Dave: 29:55

So I think compounded versions of medications will continue to become larger and larger part of the landscape of accessibility over the next year, and I think you're going to see a tug of war continue to happen between pharmaceutical companies and providers that are providing access to compounded versions of medications. You see that yesterday the FDA came out with new guidance on sort of trying to tamp down some of the misinformation that goes on online from creators that are pushing medication. Like nowhere else in pharmaceutical industry can you have people out there making outrageous claims about medicines, but it sort of goes unabated on social media because you're just an influencer, so you see them pulling back on that. You see, you know Lilly's going after some of the sources of some of these sketchier versions of these, so I think you'll continue to see more and more of that in the next year. Three years from now, I think, is a lot brighter right, because in three years from now we're looking at or for glupron, which is the oral small molecule from Eli Lilly will be will hit the market sometime in 2026.

Dave: 31:02

I think orals are the dark horse. Oral versions of GLP-1 medications or incretin memetics are the dark horse savior that we're waiting for when it comes to accessibility, because by that time you're going to see a lot of people who have successfully lost weight on Zetbound or Wegovi and they'll be able to move to more of a maintenance drug and perhaps those orals or even what we currently have, which is generic liraglutide those are going to be really great options that are going to free some of that capacity up. And within that same window that three-year window that takes us to 2027, we will have Cagrasema, we will have Red or TrueTide, so we'll have the next generation hitting the market as well for people who haven't responded to the current treatments as well, and those excite me probably the most more than anything because you're talking about new pathways of weight loss. Right Now we're dealing with the, with the, you know, sort of central weight loss. It sort of acts in the brain too. I mean, obviously it's doing other things in your gut, but it's made primarily acting in your brain to turn that switch off that tells you to eat. And so you're talking about retatrutide that adds the glucagon component that's actually revving up your metabolism, so some of that more peripheral weight loss. You're talking about amylin agonist and cagrosema, so amylin, which is co-secreted in the beta cells of the pancreas with insulin, and I think that's a real sleeper for diabetics, because if you're diabetic you're insulin resistant. I don't know, is there amylin resistance? If you're not making enough insulin, are you also not making enough amylin? So that one is a diabetic probably excites me even more than Reta-Tru-Tide does, and that one will get before Reddit, truetide. So 2026.

Dave: 32:45

Looking out five years from now, I think it's just it's almost hard to imagine, because what is really exciting to me is Novo Nordisk and Eli Lilly.

Dave: 32:56

Of course there's other pharmaceutical companies that'll jump in, but they're gobbling up these AI companies. And when I think about AI and the potential for AI to sort of come into the game and really just shift the timeline right. I think that's what AI has the capacity to do All these clinical trials that are wasted right now with molecules that don't pan out on the down low. I sort of think AMG-133, which is a new one that Amgen is working on that is actually a GLP-1 and a GIP antagonist, right, I think that one I'm not sure that's going to pan out because of what you're seeing with such harsh side effects. But you think about all the money Amgen is putting into those trials and it's crazy engines putting into those trials and it's crazy, right.

Dave: 33:48

Ai has the power to just identify the molecules with a strong likelihood to succeed in certain subsets of patients. So I'm excited for five years from now for there to be more individualized treatments from a strictly pharmaceutical standpoint, more individualized medications that maybe tailor more cocktail-y versions of medications. You talk about the quality of weight loss. Eli Lilly purchased a company that has an asset called the Magromab, which is a muscle preserving antibody. They're talking about coupling that with terzepatide and retitutide, so that's a super exciting one. Five years from now, I think, we'll be talking less about the ability of these medications to to bring down weight and like how they can do that better in certain individuals with certain situations and improve the quality of that weight loss as well.

Dr. Weiner: 34:40

Yeah, that's exciting.

Dr. Weiner: 34:41

Isn't that cool Um yeah, and I I think you know, just to add onto that, something I think that we'll see around five years is better pharmacogenetics, where from a simple blood test, you can say, oh, there's seven medicines out there, you're much more likely to respond to these two than the others.

Dr. Weiner: 35:00

And I think AI is going to play a big role in that. You know you can analyze all these people's 23andMe data and you see this, I'm sure, in your communities there's some people who just lose weight like crazy. They take the 0.25 dose of semaglutide and they lose 14 pounds in the first month, right. And then there's other people who take 0.25 and they lose zero weight. And you know, it's not that the first person is doing everything right, nutritionally and lifestyle wise, and the second person it's usually the opposite, actually that the person who's not losing the weight is the one trying the hardest at it. And so I think being able to just like you're talking about, using AI to kind of fast forward that drug, that drug production and drug development process, to also look at it from a patient perspective and be able to to get people on the right therapy faster and and and with more accuracy- I think, absolutely.

Dave: 35:55

That's just an exciting thought to to think about five years from now and I think you're you're exactly right just finding, finding the tools to identify what certain people are going to respond to and what they're not. That's a really exciting thought.

Dr. Weiner: 36:11

Listen, this has been an amazing conversation and the best part of it is is the conversation's not over, because I'm we're recording your show. I think, actually, your show will probably come out before this, but I think I'm recording your show next week or this week. I'm recording your show this week, so we have a lot more to talk about. We're going to continue it on your podcast on the pen. So I think if you like our podcast, my hunch is you're going to like Dave's podcast as well on the pen.

Zoe: 36:38

Thanks so much for being here with us.

Dave: 36:40

I appreciate you giving some time here. Like I said, it's it's awesome to come to somebody else's platform and have a conversation that way. I really enjoyed it and I really look forward to our conversation on Thursday as well.

Dr. Weiner: 36:51

Absolutely Well. You can come back anytime. This was a great conversation. Zoe, I think I'm two for two in terms of meeting awesome people on.

Zoe: 36:59

TikTok I'd say so Right.

Dr. Weiner: 37:00

Yeah, so people give TikTok a bad rap and you can't for sure get sucked into it. But I'm going to go try to meet some more interesting people on TikTok.

Zoe: 37:09

I'm excited to see who you bring to the show.

Dr. Weiner: 37:12

All right. What do we have for our nutrition segment?

Zoe: 37:15

Well, today's nutrition segment. We've kind of touched on before this concept of health halos, yes, right, but it has kind of come back to the surface in our nutrition program. Specifically, last week I had a lot of conversations about this because somebody was sharing with me about how they have been vegan for two decades.

Zoe: 37:39

However, in the past couple of years, gained a significant amount of weight and specifically pinpointed it to the Trader Joe's vegan snacks and I think that really sparked why I wanted to talk about health halos today. Because it goes to show that just because it's from Trader Joe's, just because it says it's organic, just because it says it's vegan, just because it says it's vegan, if it's a highly processed food that has a lot of ingredients, that has added sugar guess what Sugar is vegan. So there are all of these factors that can play a role in promoting weight gain not having the strongest metabolic health right, diabetes, all of these other things. Just because it has really good marketing and you think it's healthy does not automatically mean it is. So we have to be very diligent on being our own advocate and being able to read labels and read the ingredients list and know that just because it's from Trader Joe's does not automatically mean it's healthier, and I've seen this all over. This is a really common thing, trader Joe's.

Zoe: 38:51

Speaking of TikTok, actually I saw a TikTok that it was this. It was like a marketing guy that was dissecting the marketing for Trader Joe's and how they do. And I'm not. I'm not saying Trader Joe's is bad, trader Joe's is great. I'm just saying specifically the marketing. They've done a fabulous, fabulous job at marketing their, their, their community. Right, it's like.

Dr. Weiner: 39:18

It's like a and the people who work there, man, they have great work culture. I mean great. We have great work culture in our office too, for sure, but so does Trader Joe's.

Zoe: 39:29

Yes, exactly, but but then you look at where specific products are sourced. It's the same as like the. I don't know the exact example, maybe the, the pretzel, peanut butter covered pretzels or whatever.

Zoe: 39:43

Same, exact, exact formula for what's sold at Costco versus what's packaged and made it seem a little bit more healthy at Trader Joe's. So I just I really wanted to set like, have a bit more conversation, shed some light on the health halos and ultimately boiling it down to we know we want to be eating as many one ingredient, whole unprocessed foods as much as possible, and doesn't always work that way.

Dr. Weiner: 40:13

I mean trader joe's. It's a great store I love. It's a smaller grocery store. I think the grocery stores are just too freaking big. There's just too, many choices.

Dr. Weiner: 40:21

That's not good for us. Um, trader joe's has done a good job, kind of keeping everything small. But really think about the layout of Trader Joe's. They are the master of the snack. I mean their gummy candies, their ice cream, all of their chips and their caramels and chocolates and I mean a huge portion of the store is really selling snack food and so they have produce and I like they sell it by the piece instead of by pound and there's a lot of great things and I love Trader Joe's and I go there all the time. But man, you got to be careful. You can load your cart up with snack food.

Zoe: 41:02

And another really big area that they have a market on is frozen meals. Like just because it's orange chicken from Trader Joe's does not make it better, Like it's still gonna be it's like they have.

Zoe: 41:16

Just, they've done an amazing job. But speaking of the layout, I've gotten on a tangent now but I think it's interesting. They have been very specific in how they actually make it feel cramped and crowded and kind of like hard to navigate traffic in there, so that you kind of get put on this crazy path to keep adding snacks to your cart.

Dr. Weiner: 41:38

Yeah, you're always passing by the snacks there. So, yeah, I think that's a great point, which is that, again, that vegan and you'll see gluten-free. I actually just talked. We diagnosed a patient as part of their pre-op workup. We diagnosed him with celiac disease and I talked to her about gluten-free. That's beautiful and how. There's your right, there's your bonza pasta You're a big fan of the pasta, of that pasta brand, right. But then there's also the brown rice syrup, gluten-free cookies and all that stuff which is just crap without gluten, and so you have to watch these health halos. Gluten-free does not mean healthy. Vegan does not mean healthy. Sugar-free does not mean healthy. In fact, most of the time, these terms are used to hide the fact that it's heavily processed.

Zoe: 42:28

Yeah.

Dr. Weiner: 42:30

You don't see bananas with a gluten-free label on it, right?

Zoe: 42:34

Okay, let's go into questions.

Dr. Weiner: 42:36

Sierra. What do we got this week?

Sierra: 42:39

First question we have here is from our Instagram post on do I have to give up alcohol and tobacco forever? Hi Dr Weiner and Pound of Cure, if I drink in moderation after gastric bypass some weeks one drink, some weeks up to seven drinks are there any physical side effects that might be going on that I'm not aware of, that I should be wary of? I am two years post-op and so far keeping 45 kilograms off.

Dr. Weiner: 43:06

Okay, so this is a gastric bypass patient who is drinking alcohol. We've talked a lot about that. I think one of our podcasts was pretty heavily focused on alcohol use after bariatric surgery and so I think it's important for us to really talk about what an appropriate amount of alcohol is to drink. And this is again, know again, kind of getting into our culture. And we went to our family, we went to see a Doors cover band this weekend. It was really fun, but even like you know and great, nothing against the band or anything, but he was like drink up, everybody have drinks, everybody should drink. And we all kind of look at that like drinking equals fun and you should drink so that you have more fun. And that's just our culture.

Dr. Weiner: 43:51

We kind of really endorse and support large amounts of alcohol consumption, but we also know that alcohol is very unhealthy, very fattening, and it also in gastric bypass patients, is particularly dangerous. And so I think what's the right amount of alcohol to drink in a week? I think two alcoholic beverages or less per week is appropriate. And I'd love your thoughts and I think that's from someone more in weight maintenance mode but I want to hear your thoughts about alcohol in terms of weight loss. But I think that's to me a reasonable number where it's unlikely that you're developing an alcohol use disorder, that it's unlikely that you're using it in an irresponsible way.

Dr. Weiner: 44:36

And so when I hear this is someone's drinking seven drinks in one week after a gastric bypass, even if that's a drink every day, to me that's a red flag, because what happens with this is it's not like I go from zero to total alcoholic in six months. It's like year one, I'm drinking two drinks a week. Year two, I'm having a drink almost every day. Year three, I'm starting to have sometimes two drinks. And year seven, I'm really struggling with controlling my alcohol intake. So to me, I want to make sure that this person's not on a path that could potentially lead to a dangerous relationship with alcohol. One drink, no problem. Seven drinks in a week to me is beyond the limit of what I would be comfortable with one of my gastric bypass patients drinking. And if someone came into me and said they were having a drink every day, I would really work to help them cut down on that.

Zoe: 45:35

Yeah, and in terms of from a maintaining that weight lost, those seven drinks not only from the potential dependence side of things, but from a caloric consumption side that can easily get you to see weight regain and it's it's very easy to you know, depending on what specifically those drinks are, could maybe have some extra sugar. So it's just a matter of okay, with those two drinks or less a week, it's not going to be adding in a ton of empty calories, but if you're drinking seven, then that could very easily put you over in terms of, like, over time, gaining that weight back.

Dr. Weiner: 46:23

Yeah, what drink do you think if someone says, okay, I'm going to limit myself to two drinks a week? And again, my best recommendation for a gastric bypass patient is zero alcohol. But you know, let's. Let's just say my second best recommendation is two drinks or less. So let's say someone's going to follow my second best recommendation what alcoholic beverages should they, you know, are the best and which ones are the worst?

Zoe: 46:47

Good question. So we always well, we, I think you probably agree with this I like to recommend, if you are going to be drinking, doing the hard alcohol, so maybe vodka or tequila, something like that, and a zero sugar or low sugar mixer like a LaCroix or sparkling water, maybe some lime juice or some lemon juice, um, uh, and, and that way you're really only getting the calories what about like the true?

Dr. Weiner: 47:15

I think trulies are like that.

Zoe: 47:17

There's a few brands that do that a lot of them use artificial sweeteners yeah, well, those the trulies um and like the high noons I've been enjoying the high noons personally, because they're they're made with vodka, versus a malt liquor Like the.

Zoe: 47:33

The malt alcohol is like with the white claw or the trulys, um, but yeah, zero, zero added sugar, which is great, um, and and some of them do have artificial sweeteners, but some don't. So I would say trying to stay away from the sugary drinks, being careful of that. And also, you know, like beer is going to be a high, high sugar, high carbohydrate drink, obviously a lot of cocktails that you were to order out at a restaurant is going to have a lot of sugary mixers. So definitely being aware of those ones. So I would say try to go with just the liquor and a zero sugar.

Dr. Weiner: 48:13

What about red wine?

Zoe: 48:15

Well, that one is going to have some sugar just from the grapes and, depending on if they add sugar or not, but, as we know, in moderation, could potentially not be the worst thing.

Dr. Weiner: 48:30

They talk about some of the phytonutrients, like resveratrol and red wine. I agree, I think you're right Like high noon or some form of seltzer with a hard alcohol, keeping the calorie count as low as possible. And, truthfully, keeping the alcohol count as low as possible. I mean there's some beverages that are 7% 8% alcohol and others that are 4% or 5% alcohol, and so, looking at the lower alcohol versions as well, I think that's going to just be naturally lower calorie too.

Zoe: 48:57

It might be more so about the socialization of having your drink. So if you're at home and you can make your own, or you're at a party or whatever it is, you can put a splash of alcohol and mostly seltzer or sparkling water, so you don't have to do a full shot too, if it's more so about that kind of just social interaction.

Dr. Weiner: 49:29

Yeah, I think that's a great point. Nobody says you've got to put a full ounce of alcohol in the drink. Right, Put a half ounce and call it a drink and stick a lime wedge on the end and the edge and that's what you're drinking. And so I think all those strategies are really important for weight maintenance and for just general health. And you're younger than me. I think, as I get older man, just even one drink sometimes will mess me up the next day. Yeah, Certainly mess up my sleep.

Zoe: 49:56

Oh, and and same, and that's why, at this point, it's like I value my sleep so much more than I value that you know one drink, maybe.

Dr. Weiner: 50:06

I absolutely hear you. Yeah, yeah. If there was a drug that could make me sleep for like 12, like great sleep for like 12 hours, I'd probably be an addict. All right, what's our next question, sierra?

Sierra: 50:18

Okay. This one is from our YouTube video on the metabolic reset diet lowering your set point with food. I've had anorexia for two years, lost 20 kilograms and have been eating less than 500 calories a day for months. Any tips to fix my metabolism is so appreciated. Should I start lifting weights?

Zoe: 50:41

So I first want to address this question by saying you know, with a history of an eating disorder, seeing an eating disorder specialist is my number one recommendation, because it is so much more nuanced than just a simple fix or a simple answer on a podcast If that's not something that you've explored yet, I highly recommend that and also working with a mental health specialist, because the two are so closely intertwined. So, definitely seeing a specialist. There are many registered dietitians who specialize in eating disorders. But let's say your eating disorder is no longer highly active and you're working on slowly increasing your food intake and your metabolism. I would say, just like with weight loss baby steps, starting slow, making small changes. I would recommend a similar thing here. If you're right now baseline 500 calories a day, where can we make little incremental changes in your day to healthfully increase your nutrition? And yes, lifting weights, that's going to help increase your metabolism, but that would not be my priority. My priority would be increasing your metabolism through increasing your nutrition.

Dr. Weiner: 52:04

Yeah, I think the metabolic reset diet is really a good diet for someone who's struggling with anorexia Again, of course, assuming that your counselor is in support of this but because it forces you to eat.

Sierra: 52:21

Right.

Dr. Weiner: 52:21

You have to eat a pound of vegetables, you have to eat half a cup of beans every day, and so if you're going to successfully follow our diet, you must eat those foods. And so it really starts to get away from this idea that eating and food is the enemy, and just avoiding food and somehow learning how to suppress your hunger, uh, is the goal of of weight control. It changes it from actually nourishing yourself to to be healthier, it from actually nourishing yourself to be healthier. And so again, kind of getting away from this concept of I'm eating to be thin and much more toward this concept of I'm eating to be healthy.

Dr. Weiner: 52:59

And to support my metabolism and to support my metabolism Because absolutely and I think the person who posed this question already has recognized that eating this way is going to make it very difficult to kind of maintain a, a, um, a healthier way it's going to influence your metabolism going forward and so the less less of that you do. I think a metabolic reset diet has some healing capacity there, especially if you you know they did it for two years but that's. You can recover from that.

Dr. Weiner: 53:31

Like that's especially if you're younger that's not set in stone, Like your metabolism can completely rebound and recover from whatever damage has been done. I think that's another really important point is that this is not whatever changes have been made are not, are not unchangeable, unmodifiable. Good, you know, interesting question. Good, I wish this person well.

Sierra: 53:53

Okay. Last question is from an Instagram DM from Amy. Hello, I wanted to see if you could address how to handle if you miss a dose of your semaglutide. What's the best practice and are there any recommendations? I'm on the lowest dose of compounded semaglutide non-FDA approved but it was prescribed by my primary care doctor, who has been with me my entire journey. Taking once a week, same day at the lowest dose, was still causing side effects of low energy and nausea, even with good eating. I've been taking it every 10 days rather than every seven. I'm curious on your thoughts on this as well.

Dr. Weiner: 54:33

So you know, first of all, the lowest dose of compounded semaglutide. I don't know what that is. I would assume it's 0.25, because that's what we start at with the medication. When I've looked at compounding pharmacies, that's usually what I see. But the truth is 0.25 is to some degree a homeopathic dose for most people. Most people barely react. I believe that this dose is really designed to kind of find that very small group of people who have a pretty strong negative reaction to semaglutide and to not overwhelm them with too much medication where they might be sick for weeks. So generally, a lot of people don't lose any weight and don't experience anything off of 0.25.

Zoe: 55:13

It's more so.

Dr. Weiner: 55:14

Just that titration, yeah, it's just that kind of almost get going dose right.

Zoe: 55:19

Weed out the people who aren't able to tolerate.

Dr. Weiner: 55:22

So I think the second thing to talk about, just in our dosing strategy and our practice, we don't follow the FDA guidelines.

Dr. Weiner: 55:29

I think there's some people out there who are like we go exactly by how the study was done, and I think we have enough experience at this point and I've been in practicing medicine for 20 years now I understand the way that the studies are done.

Dr. Weiner: 55:45

The way that the FDA has recommended things isn't always the best for your individual patients and I think we certainly read all the studies and review that, but we have patients on once every 10 days semaglutide. We've had patients on once a month semaglutide. I mean, we work with people to figure out the thing that's going to work best for them and their life and their pocketbook and all of the other factors that are involved in dosing these meds. So I mean the best thing to do if you miss a dose is just take it and keep going, right, you know, keep dancing, and I don't know that you really need to be modifying things in any way. I mean, I think the important part too is that, as we've talked about, you know over and over again how important food is with this and the right diet.

Zoe: 56:31

So yes, definitely I. I just wanted to kind of mimic what you were saying in terms of the dosing strategy. Is that that you and our other providers employ is very individual driven, right it's? How are you? You're not going to increase the dose if they're losing weight?

Zoe: 56:49

yeah you're, you know they're, you're not going. So increase the dose if they're losing weight. You're, you know they're, you're not going. So there's all these different types of things that do not follow exactly as the study says, but it makes it so much more like the patient is in the driver's seat in terms of you guys matching their response and the care that you're providing so that they get the best results and the minimized side effects.

Dr. Weiner: 57:12

Yeah, absolutely All right. Well, I think that wraps up another episode.

Zoe: 57:18

This podcast is produced by Sierra Miller and Rhiannon Griffin, and the editing is done by Autogrow. Thanks especially to our guest Dave, who, over on YouTube, tiktok is on the pen that's the name of his podcast, so go check him out there. Please check us out on social media or at our website and consider joining our online nutrition program or Pound of Cure Platinum program If you are in need of some more personalized assistance. See you next time.