Tag: Weight Loss Medication

The Health Crisis of Obesity: Understanding and Overcoming a Modern Disease

obese person measuring themselves around the waist

Recently, I was out having dinner with some friends and my phone started blowing up. 

 “Are you catching this piece on 60 Minutes about obesity?”

“60 Minutes is talking about Wegovy – you have to watch!”

This piece is an excellent commentary on the issues of obesity, and how medications can help treat this disease. That said, I am very disappointed that the focus was just on one medication, and not on the vast complexities of obesity. There are 4 pillars of obesity medicine that play a role in lasting weight loss: nutrition, exercise, behavioral modification, and medical management (which includes disease reversal).  

As I’ve stated before it’s important to look at who is paying for the piece and what is the angle. Let’s take a deeper dive into answering these questions, and how we could have made this more beneficial for the millions of folks fighting obesity in America and throughout the world.

Obesity IS a Disease!

Let me start by saying that I know and respect Dr. Carol Apovian and Dr. Fatima Cody-Stanford.  In fact, I fought side by side with them ten years ago in my leadership position with the OMA (Obesity Medicine Association) to convince the AMA (American Medical Association) to recognize obesity as a disease and we won! What’s amazing to me is ten years later, we are still trying to convince society that obesity is in fact a disease. Why is this?  

It’s never a bad idea to follow the money. As stated in this 60 Minutes piece, the case has been made and won that obesity is a complicated, multifactorial disease that contributes to at least 13 cancers and hundreds of diseases. Many of these conditions are treated with more medications that further weight gain, causing more obesity-related diseases (ORDs). Before you know it, you are on seven medications to “treat” or “control” these ORDs! 

There are a few problems with this piece that I’d like to point out here. 

Problem #1:  Why Don’t We Use the Language Disease Reversal? 

In this piece, which was sponsored by Novo Nordisk (makers of Wegovy, and several other medications used to treat diabetes and other conditions), we keep hearing how we must “manage” or “control” ORDs. Isn’t that interesting? Follow the money. 

It’s true that obesity is complicated, but we now have plenty of proof that a 5-10% weight loss can reduce and in many cases reverse obesity-related diseases. Unfortunately, these same drug companies that make the AOMs (anti-obesity medications) make the meds to treat obesity-related diseases. What a conundrum. 

Problem #2: The “Magic Drug” Phenomenon

Here we go–the war on drugs. There are several classes of anti-obesity medications (AOMs) available including the GLP-1s which have been all over the news lately. Some of these include Wegovy (by Novo Nordisk), Ozempic (which is the same as Wegovy), and Mounjaro (by Eli Lilley).

There is tons of money to be made by whoever can control the obesity market, yet still stay in the game with the meds that treat obesity-related diseases. I’m a minimalist, and my job as an Obesity Medicine Physician is to get folks healthier and reverse as many diseases as possible through weight loss. I like and use all three of the medications listed above. If I can use one drug to get a patient off six, and there is ample supply, I will do it. Up until now, however, Wegovy has not had ample supply. Coincidentally, just before this 60 Minutes piece came out, I received a letter and visit from my Novo Nordisk rep informing me that suddenly the problem was fixed. Well, we will see–this has been an on-and-off problem for all of these medications (GLP-1s) for a long time.  

So back to the “magic drug” phenomenon. Let’s assume everyone has an ample supply.  That does not mean that you can take Wegovy and go eat whatever you want, not exercise, drink too much alcohol, stay up late, caffeinate too much and lose 50 pounds like your friend did. In fact, I will argue that you will be the one writing nasty comments on my Instagram account about how the drug made you sick and that no one should take it.  

The point is, you need to have a sufficient nutrition plan in addition to healthy eating behaviors, adequate sleep, and exercise. If you take this class of drugs (GLP-1s), you must also know how to titrate the medication appropriately (with the help of an experienced doctor) to minimize any side effects. This 60 Minutes piece doesn’t show everything that’s involved in experiencing success from taking this drug. It only shows you one woman who took it and lost weight, and another that didn’t and is still struggling. 

Let me let you in on a secret…shh, don’t tell anyone…THERE IS NO MAGIC DRUG. You must manage the other components of your life to benefit from the prolonged weight loss anti-obesity medications have to offer. There is no way around it. Sorry (hands up emoji).  

Problem #3: It’s About Shame and Genetics. Period. 

Oh did I hear about this one!   

Obesity is complicated. VERY complicated.

Genetics plays a role, as does shame for some folks, but there are a number of other factors that contribute to obesity: 

  • Environmental factors (Epigenetics)
  • Produce that is genetically modified
  • Meat and poultry that is fed with all sorts of bad stuff
  • Our increased use of technology and decrease in overall movement
  • The fact that healthy food is more expensive, and that much of the fast food and shelf-ready food offered to us is addictive
  • Psychosocial issues like childhood poverty, neglect, and abuse that formulate dysfunctional eating behaviors early in life
  • Untrained physicians and other providers who lack empathy even though many of them struggle with their own weight
  • Lockdowns during the pandemic where the average American gained 50 + pounds

The list goes on…

Finally, top it with medications for obesity-related diseases that cause further obesity as previously mentioned and there you have it–the hot mess that we have been calling the obesity epidemic for over 30 years.  

It’s complicated for sure, but fixable, very fixable! But not with a magic pill or drug alone. 

If you’re struggling with your weight, find an obesity medicine physician in your area and get expert help. If your insurance will not cover it, lobby your employer to provide benefits. Don’t give up the fight! You may start hopeless but you will leave victorious. And if you’re in the Central New York area, come see me! The Medical Weight Loss team would love to help you.

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4 Myths About Ozempic From an Experienced Weight Loss Doctor

woman drinking coffee outside on a cold day

It’s amazing to me how quickly a drug that has helped so many people lose weight, keep it off and reverse their diabetes (yes, I said reverse) became an enemy of the state. I tell my students and colleagues who I train and my own children quite frankly, to question everything you see in the media. What’s the angle? Who wrote it? Who stands to benefit (financially) from this opinion? 

As a private practice physician with no ties to big pharma, and no mandates on pathways I must take from any hospital system, I am writing this article to set the record straight on the myths and truths about Ozempic.

Myth #1 – Ozempic is being prescribed off-label. That is dangerous!

As mentioned in our previous article, Wegovy and Ozempic are both brand names for the drug Semaglutide. Wegovy is generally prescribed for obesity at a maximum dose is 2.4 mg and Ozempic for diabetes at a maximum dose of 2.0 mg. Since it’s the same drug, how can it possibly be considered off-label use when prescribed for one condition versus the other? The difference is the brand name, not the formulation. Therefore, it is a branding issue, NOT a “safety” issue.  

Myth #2 – Ozempic should be reserved for diabetics, not patients with obesity.

As mentioned above, Ozempic is the brand name for Semaglutide, a drug also branded as Wegovy for weight loss. It’s the same drug! Why is diabetes a more important disease than obesity? In fact, I would argue that the opposite is true. Since at least 90% of type II diabetics are overweight or obese1, it would make more sense to prescribe this medicine for obesity, since weight loss can reverse type II diabetes altogether. Plus, obesity is associated with over 200 diseases2, not just one. This is not a “disease hierarchy” issue.

Myth #3 – Ozempic is very dangerous and causes crippling nausea and bowel obstructions!

Any doctor experienced in writing this class of drugs (GLP-1s) will tell you that you must start low and go slow! You must never go faster than the suggested titration rates when stepping up to the next dose, and sometimes should proceed slower if a patient is struggling. These are nuances learned over time with experience, that a doc-in-a-box flippantly prescribing Ozempic may not know.

In my practice, I will never increase a dose until the patient is free of nausea and constipation. If you do this, the above side effects are minimal. I have never seen “crippling nausea” and have never written an anti-nausea drug with Ozempic. It is not necessary. I have also never had a patient in the hospital with a bowel obstruction cause by this drug. 

Myth #4 – If you stop Ozempic, you WILL gain the weight back. 

This is a question I get frequently from patients on anti-obesity medications, so I tell them the following:

“If you are on a medicine for blood pressure, do you stop it when you reach your goal of 120/80?”  If the answer is no, why would you stop an anti-obesity medication when you reach your weight goal?

Additionally, in the last ten years, we have learned that a process called “metabolic adaptation” causes our hunger hormones to rise, fullness hormones to decrease, and metabolism to decrease with weight loss, pushing us back to our “set point” weight.3 Because of this, it is very hard to maintain significant weight loss if you stop medications that counter that process, such as those that control hunger or increase metabolism.   

The National Weight Control Registry, however, has shown that it can be accomplished if you exercise 1-1.5 hours per day, document your food, get good sleep, use meal replacements, and incorporate other behavioral measures consistently. These are great tools, but the exercise piece is hard for many of my patients to maintain for a variety of reasons. Anti-obesity medications help patients keep weight off long term, and if started should be continued.  

Using Ozempic in a Busy Medical Weight Loss Practice

Ozempic was FDA-approved in December 2017 for type II diabetes. However, due to excellent cardiovascular prevention data, most insurance companies will now cover Semaglutide for pre-diabetes as well. Ozempic is started at a dose of 0.25 mg for 4 weeks, then 0.5 mg for 4 weeks, titrating to 1 mg weekly for 4 weeks. 

Earlier this year, a 2 mg dose was approved which has been a game changer, nearly doubling the 6.1% body weight loss seen on the 1 mg dose in clinical trials (resulting in 10-12% weight loss in our patients). As mentioned above, side effects are decreased by taking the time needed for a patient to adjust to each dose before titrating up, even if it requires a slower titration process.  

As with many medications, we have been seeing supply chain issues with Ozempic that are off and on for different doses. At the time of writing of this blog, the 2 mg dose is not available, so I’ve had to move many patients down to 1 mg or hold them there. I have not noticed weight gain when I do this, but the loss is not as pronounced on the lower dose. We are seeing the same issue with Wegovy, and now Mounjaro, which is made within the United States due to supply chain issues. To improve the situation, compounding pharmacies have received approval to manufacture Semaglutide, but it is still quite costly (several hundred dollars) and may not be covered by insurance.   

References: 

1 National Diabetes Statistics Report 2020 https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf 

2 Obesity as a Disease: The Obesity Society 2018 Position Statement. Obesity (2019) 27, 7-9. Doi: 10.1002/oby22378

3 Obesity 2016. Persistent metabolic adaptation 6 years after “The Biggest Loser” competition.  Aug;24(8):1612-9. doi: 10.1002/oby.21538. Epub 2016 May 2.

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Phentermine for Weight Loss: Everything You Need to Know

pill bottle with a tape measure wrapped around it

What is Phentermine?

Phentermine is an FDA approved appetite suppressant pill that has been on the market since 1959. For over 60 years, phentermine has been the most commonly prescribed diet pill in the world.

Phentermine is a sympathomimetic. It is similar in character to the drugs that are used today to treat ADD or ADHD. It works at the level of the hypothalamus to decrease hunger and through its stimulatory effects, increases metabolism.

Because it is similar in structure to stimulants, some patients may experience a “speedy” or “energized” feeling when they first start taking phentermine. This resolves once your body becomes used to the medication, which is typically within the first few weeks of use.

When used correctly, phentermine is safe and inexpensive. When starting phentermine at 37.5mg (the dose used in our office), you should always start with a half pill. It is scored and easily “split-able” by hand or you can use a pill splitter. You may increase the dose to 1 whole pill daily if you begin to feel like the medication is not suppressing your appetite all day.

How is Phentermine Taken?

Phentermine should be taken on an empty stomach so that it can be absorbed properly and work most effectively. It is highly recommended that you take phentermine immediately upon waking so that it does not affect your sleep. You should wait at least 1 hour after taking the medication to eat. Drinking water or black coffee during this 1 hour after taking the medication is fine.

If you eat small breakfasts or no breakfast at all, you may choose to take your pill at 10 or 11 o’clock in the morning when your stomach is not full. Taking it later in the morning is also an option if you fall asleep easily and are a sound sleeper as it will last later in the evening. This tends to prevent evening hunger and cravings.

How Long Can You Take Phentermine?

Provided there are no contraindications or significant side effects, phentermine can be taken as long as necessary to achieve a patient’s treatment goal. It is also an important tool to help maintain weight loss, as it increases metabolism and decreases hunger. Phentermine fights against the body’s natural tendency to push one back to their set point weight.

Side Effects of Phentermine

Most patients who take phentermine will experience a dry mouth. To minimize this sensation, make sure that you drink plenty of water, which for most people should be 60-100 ounces per day.

Some patients will experience mild constipation. Again, keeping your fluid intake high can prevent this. If you are reaching your water goals and still struggling, you can take 2 tablespoons of milk of magnesia morning and night until the constipation subsides. Another option is to use polyethylene glycol powder (Miralax). Dissolve 17g in 8 ounces of water or another beverage daily until the constipation subsides.

All stimulants can potentially raise your blood pressure. If this happens, it is generally mild. If you take medication for high blood pressure, keep a blood pressure journal that has 3 weekly readings. This will help the providers to know how your blood pressure is doing at home and at work. If you don’t own a blood pressure cuff, you can check it at just about any pharmacy. When your weight significantly drops, expect your blood pressure to come down also. This may require taking you off your blood pressure medication.

Who Should Not Take Phentermine?

There are some patients who should not take phentermine. Providers will carefully screen your medical history and list of medications to make sure that you are able to take it.

Do not take this medication if you have:

Phentermine is an FDA approved appetite suppressant that helps patients lose weight and maintain that weight loss. This medication must be taken on an empty stomach and you should drink plenty of water daily while taking it. Phentermine is not addicting and can be started and stopped at any time. For additional information, speak to your provider, or call our office at (315) 445-0003.

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