Imagine reducing your risk of cardiovascular diseases and cancer while transforming your body through weight loss. Our latest episode takes an exhilarating deep dive into the world of bariatric surgery and GLP-1 medications, exploring their potent effects on heart disease and cancer. We uncover the dramatic 25% dip in cancer risk post-surgery and put GLP-1’s heart benefits under the microscope, comparing them to the tried-and-true statins. Hear a moving account from a patient whose weight loss journey might signal a new era in medical treatments for obesity.
Embarking on a personal quest for weight loss isn’t a one-size-fits-all affair. We shed light on the diverse paths individuals embark on, from the operating table to the pharmacy, and dissect the factors influencing these life-altering decisions. In a nutritional detour, discover how lentil pasta’s high-protein, high-fiber content can revolutionize your diet—without the exorphins that fuel overeating. We also peel back the curtain on weight loss strategies and the often-overlooked aspect of medication costs, providing you with a guide to navigating these complex waters.
Addressing your burning questions, we provide personalized insights into Ozempic dosing for weight loss and demystify concerns about metabolism rates—information that just might reshape your weight management approach. Furthermore, we serve up advice for those on plant-based diets and offer alternative metrics to measure health progress, stepping beyond the confines of the scale. Wrapping up, we tackle the misconceptions about GLP-1 medications, addressing the fears surrounding medullary thyroid cancer and pancreatitis with the precision of a seasoned clinician. Join us for this episode, where each listener finds a tailored path to health and well-being, all backed by the latest scientific insights.
Transcript
Zoe:
All right, well, welcome to our next episode here of the Pound of Cure podcast, Canadian Mounjaro, eh. Today we will be covering cardiovascular and cancer risk in our news segment. We’ve got a nice patient story for you, our nutrition tip of the day, as well as our questions from the audience. So we’ve got questions about dosing on Ozempic, metabolism. We’re also talking about Paxil supplementation, measuring success off of the scale, thyroid tumors and pancreatitis.
Dr. Weiner:
All right, lots of cover.
Zoe:
Lots of cover, big, wide variety.
Dr. Weiner:
Yeah, for sure, for sure. So let’s get right into this and move into our news segment. So there’s been a lot of talk about, of course, the GLP-1 medications, and everybody knows that they were initially diabetes medications. They’re really helpful in lowering your blood sugar. We’re also seeing the effects of weight loss and these things are really fantastic weight loss tools. But there’s additional benefits and I think these benefits are interesting because we haven’t really scientifically worked these things out. So I’m going to talk first about bariatric surgery and then about GLP-1 meds. So there’s an article in medical news today that talks about bariatric bypass, which is, of course, the gastric bypass, for weight loss may cut cancer risk by 25%.
Zoe:
That’s a big percentage.
Dr. Weiner:
It’s a big percentage and actually I think two years ago our national society meeting has a theme and two years ago it was reducing cancer and oncology benefits of bariatric surgery. So this is known, this is in news, we’ve known about this for five or 10 years. But we see, with bariatric surgery, reduction in overall cancer risk of 25%. That’s a lot. That means one out of four people who were supposed to get cancer didn’t get cancer if they had a gastric bypass and I think this really points to the link between obesity and cancer. And it’s so many different cancers. It’s endometrial cancer that’s a big one. It’s breast cancer, ovarian cancer, colon cancer. So there’s all of these cancers out there that you are more susceptible to if you have obesity. That’s partly because obesity is an inflammatory condition. When you suffer from obesity, your body has higher rates of inflammation and inflammation ultimately can lead to cancer. So we have also seen significant cardiovascular risk reduction with Wegovy. There’s a study that comes out, there’s a couple of different studies – One on diabetics, one for weight loss and we’re seeing somewhere in the neighborhood of 20 to 25% cardiovascular risk reduction with the use of Wegovy. This is again, really a pretty remarkable result. This is probably better than we see with most statins. We think about statins, which we take for cholesterol. Why do you take a statin? Why do you care about your cholesterol? Who cares what your cholesterol is? Nobody’s ever walks around says oh my god, I have such a headache, my cholesterol must be up. Today. It’s really an asymptomatic condition to have high cholesterol, but we know that high cholesterol is linked to heart attacks and that by taking a statin and reducing our cholesterol level we can reduce the risk of cardiovascular events like heart attacks and strokes. So we see the same thing with Wegovy and we probably and this is something that they’re going to work out probably going to seem more we’ll see that these medications are more effective at reducing cardiovascular events than statins, which are taken primarily and only for reducing cardiovascular. You get no other benefits with that.
Zoe:
That’s so great.
Dr. Weiner:
Yeah. So the big question is why? Why is this, then? There’s two possible options. The first option is is it because these medications actually work on the heart, on the blood vessels in the heart, on the blood vessels that lead to your brain and reduce your likelihood of having a cardiovascular event, and that bariatric surgery, by rerouting the intestine and changing some of these gastrointestinal hormones, actually reduces your body’s ability to your body’s likelihood to develop a cancer cell? Is it because they actually work on that process or is it just the weight loss? Is it by losing weight do you reduce your risk of cardiovascular events? By losing weight do you reduce your risk of developing cancer? And I think that’s what we’re going to end up figuring out is that these, that Wegovy doesn’t actually prevent heart attacks. It causes weight loss. Weight loss is the intermediary and the weight loss is what reduces the cardiovascular risk. And I think we’ll find the same thing when we look at bariatric surgery literature. So this is really fascinating. The truth is, it doesn’t matter. This is kind of an academic conversation about whether it’s the weight loss or the or the, the medication or the surgery itself. How it affects you is if you take these medications, you’re more, you’re less likely to have a heart attack. If you have bariatric surgery, you’re less likely to develop cancer.
Zoe:
So bottom line is that you’re improving these health markers and you’re improving your your life expectancy.
Dr. Weiner:
Absolutely. All right. So let’s move over to the next segment. This is a patient story and this is something we’re seeing more and more of in our practice. I think I talked in the last episode about how bariatric surgery volumes are down 30% across the country. It’s even affecting like intuitive, which makes the Da Vinci robot, and a lot of people do bariatric surgery robotically. That’s probably another topic for a conversation in a future podcast. I personally am not a robot guy, but anyway, we’re seeing their stock drop as a result of people’s assumption that these GLP-1 medications are going to reduce or potentially even eliminate bariatric surgery, and this may be. We may see this in the future. It’s hard to predict. I think we’re always going to see patients like this. So this was a woman. She was in her early 30s. She just had a couple of pregnancies. She weighed 325 pounds. She was five foot five inches tall. Puts her BMI, can’t do the math exactly, but it was somewhere in the 50s, I think, definitely. You know one of our bigger patients and she had tried GLP-1s in the past, got extremely nauseous, lost a lot of weight and then developed cholecystitis and needed her gallbladder out. So she’s like forget this, I’m done with these medications. And so she opted to have a gastric bypass, and that’s something when I counsel patients on weight loss surgery you are looking to avoid medication use at all in the future. A gastric bypass is a better option than a sleeve gastrectomy because of the weight regain that we see with the sleeve, that we typically treat with, of course, glp-1 medications. So this patient said, hey, you know what I’m kind of done with these meds. They’re not for me. I don’t want to take this medication for the rest of my life. I’d rather have a surgery, one and done, and lose the weight and deal with, you know, the 1% risk of ulcers, the 3% risk of obstruction – small but manageable risks. I’d rather deal with that than taking these medications, and I think that’s something that we’re going to start to see is. This is and it’s really interesting I have one patient come in said I do not want surgery, I only want meds. Don’t even talk to me about surgery, I’m not interested. And the next patient comes in and says I want the surgery, I do not want the meds, don’t even talk to me about the meds, those things. I don’t want to be on a medication for the rest of my life, let’s just talk about surgery and it’s so interesting how people are really biased toward one or the other and you know some are okay with the meds and some are okay with the surgery.
Zoe:
So it’s just goes to show it’s so individualized right, Not only the treatment pathway but also people’s opinions and what they want, and that’s something that I think our patients really appreciate. That, you know, meeting with you and our nurse practitioners, it’s not that they have to do one or the other and we kind of have this kind of flowy back and forth pathway. If a patient wants to go down medication route and then flop over to the the surgery route and then have and then go back on medications after surgery. It’s all very fluid and I think that’s something that’s really powerful about these combination therapies.
Dr. Weiner:
Yeah, we talk all about the pyramid, right, nutrition’s at the base. That’s where you come in. Then the medications and finally the surgery. And kind of work your way up the pyramid to see what the best treatment is. The meds are nice, you can start it, you can stop them, you know the surgery. Once you have the surgery, it’s done. So there’s no going back after that. So that’s why it’s at the top of the pyramid. But it’s also the most effective route and I think you know, after about 3000 cases, we can do these things with a 1% 1.5% serious complication rate. Truthfully, most years I go, I go through the entire year without a serious complication after bariatric surgery. Absolutely.
Zoe:
Okay. So nutrition tip of the day, of the episode is I want to talk about one of my favorite products that I’ve turned a lot of patients on to, which is new lentil pasta. So there’s lentil pasta, there’s chickpea pasta. Personally, I like the lentil pasta better, just like texture wise. Other people like the chickpea, personal preference. The reason why I love these pastas is because there’s literally one ingredient. It’s just lentil flour, it’s just ground up lentils repurposed into the shape of a pasta, because they are plant-based, made out of these lentils and or chickpeas. They are going to be high protein, high in plant-based protein, high in fiber. The reason why I love these one of the many reasons why I love these pasta so much is because they’re very satisfying. Because of that high protein and that high fiber content. You need a much smaller portion to feel satisfied when you get served to play the pasta at the restaurant. It’s a huge portion, right? It’s very easy to eat a big portion of pasta when it’s solely processed white flour. You know starches. It’s a starchy carbohydrates because you’re not getting that. You might get volume, but you don’t get that same level of satisfaction because of the protein and the fiber. Obviously, it’s also minimally processed, given it only has one ingredient. So I’m a really big fan of these pastas and I recommend them a lot.
Dr. Weiner:
Yeah, there’s a lot to these pastas, a lot of really good things. First of all, the gluten that is in the traditional pastas, something called exorphans, and exorphans are what we make in our body that helps relieve pain. That’s like what you get when you’re running a marathon. Exorphans are something from the outside that you eat and that have that same kind of opioid effect. They trigger the opioid receptors. The same thing like Vicodin and heroin and all these medications. Obviously that heroin is not a medication, but all these substances.
Zoe:
I bet chocolate has it in there too.
Dr. Weiner:
Yeah, chocolate probably does have it in there, for sure, but they have exorphins in there and that triggers you to eat more and enjoy the food more and you get more pleasure as you’re eating it, which is why you eat this big bowl of pasta. You’re like, oh my God, so good, so good, so good. And then you’re like, oh, I ate so much where, when you have the lentil pastas, you don’t get these exorphins and you get the protein and the fiber, like you talked about, and so such a better option compared to the white pastas in the process of white flowers. So that’s a great tip and they are really delicious.
Zoe:
They are, and the other thing is that they really can take on any flavor. So you can do veggies in there, you can do like a homemade pesto in there, marinara sauce. I’ve even made kind of like a healthier take on tuna noodle casserole, because tuna noodle casserole it was kind of nostalgic for me and my childhood so I did a kind of riff on that and it was very good.
Dr. Weiner:
It sounds like it would be yeah, for sure. Okay. And now for the economics of obesity, and this is where we really discuss the cost of medications, the cost of surgery, just what happens if you’re struggling with obesity, because we see every single day, probably with almost every single patient. What we really talk about is what is the cost of this medication, what is the cost of surgery? What is the cost of your health insurance? How are we going to figure this out financially? And so this is where the topic of our show comes in Mounjaro, eh! Mounjaro is now available in Canada and this is big because the Canadian government will negotiate with pharma industry and because they have socialized medicine, there’s essentially one payer for these medications. So they’ll negotiate with these medications and the pharma prices are much lower in Canada than they are in the United States. They also don’t have pharmacy benefit managers who suck 20 or 30% of the cost out without providing really any value to the world. Drug prices are much less expensive in Canada and pretty much every other country outside the United States. And the Canadian government, the pharmacies will ship medications over. It’s a little tricky because Mounjaro, Ozempic, and these medications need to be refrigerated, but it’s possible to ship them over. And what we’re seeing is Mounjaro. It’s sold as a single dose vial. Most other governments are doing a lot smarter things when it comes to managing access to these medications. In the US, a big part of our supply chain shortage for Ozempic was the injector pen, not the medication itself. And so you know we’re having this crazy shortage for this medication and because of FDA rules you can’t just swap it out with a different injector pen, and so that really limited and created some of the supply chain issues we’re seeing. We saw that same thing with Mounjaro, and so the Canadian government said swap it out for a vial, that’s fine, no biggie. And so they’re being sold as a single dose vial, and so one dose, one week’s worth, is about $150, $160, which is cheaper than a current pricing of $1,200 a month for four. So about $300. So it’s about half the price of what it’s selling for currently in the US, but still that’s an exorbitant amount of money. But remember the 2.5 milligram, the 5 milligram, the 7.5 milligram, the 10 milligram, the 12.5 milligram dose all the same price. And so how that’s going to work out. Now that’s a single use vial so you can’t just keep going back in to the same vial and it’s also a very small amount. So you know there’s something to this and I think we’ll start to see this work out over time. You know, if possible, of course, you got to take the medication the way it’s intended to be used, but we’re going to see, as we see, less and less access to these medications this year. We’re going to see that this is probably going to be a huge opportunity for people to get the medication at a reasonable cost.
Zoe:
Getting creative.
Dr. Weiner:
So it’s now available. This is big. Most of the pharmacies don’t have it in stock and we’ll see the same supply chain issues that we saw here last year this year in the Canadian pharmacies, but I do think that this will get worked out throughout the year. This is going to be a big component, a big way that people are getting the medication.
Zoe:
Yeah Well, hopefully it provides, you know, a more affordable option for people who are struggling to get their medication.
Dr. Weiner:
More affordable than $1,200 a month. Yeah, seriously, seriously.
Zoe:
I find it very interesting that all of the doses are the same cost.
Dr. Weiner:
Yeah, it’s kind of the you know the proof, the proof that there’s, and again, not to you know the pharmacy industry says it takes a billion dollars to get a drug to market and our FDA approval process is rightfully very rigorous. That’s why we have such a safe supply of pharmaceuticals. But do you know who the biggest TV advertisers are?
Zoe:
No.
Dr. Weiner:
Pharma industry.
Zoe:
Uh-huh.
Dr. Weiner:
Yeah. So a huge, huge part of that cost of that drug is on advertising, which the truth is, for Ozempic, for Mounjaro you don’t need to advertise these drugs.
Zoe:
No Word of mouth. Social media like us. Yeah, literally.
Dr. Weiner:
We’re right here. You know we’re not being paid by the pharma industry and we’re talking all about how great these meds are. When a medication is this great and this effective, you don’t need to advertise for it. The biggest issue right now is I can’t supply it.
Zoe:
Maybe start stop marketing so much and start making it.
Dr. Weiner:
There you go. I think that’s way too simple of a solution, Zoe. All right, so let’s move to our next segment, questions from our social media followers out there, so we get tons of questions that come to us on social media, come to us through our website. On our website, there’s a form. On our podcast page you can submit a question to us, and so we’ve got our trusty office manager, Sierra. She’s here and she’s going to read the questions, and then we’ll kind of take turns, and we’ve identified six questions that we’re going to cover in today’s episode.
Sierra:
Um, here we go. So first question is from Angie on YouTube. Hello, my doctor gave me Ozempic but only at the.25 dose for eight weeks. Is that too low of a dose to do anything?
Dr. Weiner:
Maybe, maybe not. So when they first released Ozempic and the dosing, it all came from the diabetes space and there’s no question that diabetics respond differently to this medication than non-diabetics and I think they lose substantially less weight. I think with the in the Wegovy studies, which is for weight loss, we’re looking at about 16% total body weight loss, in diabetics, 9%, so that’s, you know, almost half as much weight loss. Yeah, it’s a big difference. When you’re diabetic, when your cells don’t respond appropriately to insulin, your response to this GLP-1 medication is very different, because there’s a small group of people who are really sensitive to these medications and because the medications last for a week or longer. The idea is you don’t want to give somebody a high dose and have them be like violently ill for an entire week. They’ll never want to touch that medicine again. So they came up with this kind of introductory 0.25 milligram dose and it was supposed to be follow it for four weeks. Then you increase it to 0.5. And the idea is and the way this was sold is 0.25 is a homeopathic dose, meaning it’s really just barely enough. It’s not really going to work, and it’s just a test dose to make sure that you’re not one of these people who’s super sensitive.
Zoe:
Introduce it to your system.
Dr. Weiner:
Exactly. But I’m not so sure with the non-diabetics that that’s a true statement, because we see people go on 0.25 milligrams and lose a ton of weight and so we generally don’t follow this. Do it for four weeks, then increase the dose. Then stay on that dose for four weeks, then increase it some more. Essentially, when we work with patients on these medications we don’t rapidly increase the dose. So the answer to this question is if you had good satiety, you lost some weight three, four, five, six, seven, ten pounds in a month and are feeling comfortable, stay on 0.25. And we kind of work through this and we keep you on the dose and as long as you’re still losing weight we stay at that low, comfortable dose. It’s not a ramp the dose up and stay on as long as possible. These medications are intended for long-term use. So whether we get you to the highest dose in three months, six months, a year, it doesn’t really matter.
Zoe:
It kind of parallels our post-op nutrition. It’s not by a specific amount of time, it’s how are you responding?
Dr. Weiner:
How are you?
Zoe:
doing. There’s not a prize when you reach a certain end.
Dr. Weiner:
Yeah, no, absolutely. It’s a great analogy. So if you’re doing well on 0.25 and you’re losing weight and you’re feeling some satiety, stay on 0.25. We see people lose a lot of weight on 0.25. We also see people go on it and lose nothing and have absolutely zero effect, and those patients we’re going to move up to 0.5. And I’m not sure it should take four weeks to figure that out. You know why not after two or three weeks. If you’re not losing weight and not having any results whatsoever and are really dialed in on nutrition and things aren’t moving the way you’d want them to Maybe go up on the dose a little early. So I think this idea that there’s this prescribed way that you’ve got to take them we need to get away from that. Everybody’s going to respond a little bit differently to these meds and we have to be able to work with you to get the dose to the right amount so that you’re comfortable but also losing weight and finding some success.
Sierra:
Okay. Next question is from our TikTok video Sleeve or Bypass. This is from Tammy. Do you ever check metabolism?
Zoe:
This is a good question. So here in our office we do not. But the reason is a little bit more complex than it’s an expensive piece of equipment, because I actually used to check metabolism basal metabolic rate, via indirect calorimetry at my old job, and the thing is is that there are so many factors that impact that number, that reading right. So whether you haven’t fasted enough, or what you ate beforehand, or if we tested it in the middle of exercise, there are your basal metabolic rate, that one piece of data that gets extracted from that test, can change a lot throughout the day based on those different circumstances. And so we like to think of metabolism more so as a whole, in terms of what you are doing, what you’re doing for your nutrition and exercise and maybe, if you’re on medication, working towards reducing that set point and that kind of thing. So no, we do not test metabolism because of that change in that BMR.
Dr. Weiner:
So that’s a great point. So first of all, how do you, how does that work? How do you test indirect calorimetry?
Zoe:
So it’s quite an uncomfortable test. So basically, you have to fast for at least, I believe, 12 hours, something along those lines. You have to get in this chair, you get all comfy, you have this mask on. We have to make sure that you have as low of a heart rate as possible. So when I was doing it, it was you can’t look at your phone just in case you read a stressful email and your heart rate spikes up. It’s trying to be as low of a heart rate as possible, which our heart rate is not as low as possible all day long.
Dr. Weiner:
That’s not when you have this big mask on your face. Exactly you can’t relax.
Zoe:
And then you sit in that chair and breathe for about 15 minutes 15 to 20 minutes and basically it measures your carbon dioxide and your oxygen consumption and your heart rate and all of that sort of thing, and so we see some really strange numbers that don’t make a lot of sense sometimes, right? And so I think it’s just important that, if you want to go get it done, it could be another piece of data to add into your toolbox. But just keep in mind, don’t take that one number as an end all be all, because it will change so much throughout the day depending on circumstances.
Dr. Weiner:
Yeah, you’re just getting a point on the curve, but if you’re really going to make a good evaluation, you need the entire curve and that’s just not possible to get. They’re trying to do that with this, the thing you exhale into I forget what that’s called. Yeah, the little hand held it’s all over Instagram or whatever and that just measures what’s called your respiratory quotient, which is a ratio of your exhaled carbon dioxide to your inhaled oxygen, or maybe it’s the other way around. I’d have to look it up but it tells you whether you’re burning fat or whether you’re burning protein or whether you’re burning carbohydrate. That’s kind of similar thought processes. How can you use that to determine what you should be eating or how you should be exercising? This is all tiny pieces of data. It’s a very blunt instrument. The human body is extremely complex. It’d be great if you could measure metabolism. It’s really hard to throughout the entire day.
Zoe:
And I think also what we have to remember is that we can get lost in the forest. What’s saying? Like lost in the trees?
Dr. Weiner:
Can’t see the trees through the forest.
Zoe:
Whatever it is, getting stuck on these very minute details and trying to track every piece of data, whether it’s measuring your metabolism and maybe a continuous glucose monitor, like all of these different data points, but not remembering general good nutrition principles and kind of over complicating things. I think it’s completely unnecessary.
Dr. Weiner:
It also, I think, leads you down some false paths. For instance, if you drank a Coca-Cola right before you sat down and had your metabolism measured, what happened to your metabolism? It’s going to go way up trying to burn off the calories that you just drank in the Coca-Cola. And so you might assume, oh, a good, high metabolism rate is good, so I should just drink Coca-Cola all the time. But that’s obviously not a good assumption to make. So I think a lot of times it kind of can reinforce or get you to think, hey, I can do these bad behaviors and it doesn’t affect me, or it might even affect me in a positive way. And so the data just isn’t, it’s not accurate. And so when you start, what do they say? Garbage in, garbage out. Right, if you get garbage data, you can’t make any assumption you make based on garbage data is going to be garbage. So all right, sierra, what do we have for our next question?
Sierra:
Okay, this one is from Juanita on our YouTube video, How to Prevent your Stomach from Stretching After Weight Loss Surgery”. She says so. I take paxil for my anxiety and it has made me gain 30 pounds. Should I still take it after my surgery?
Dr. Weiner:
All right. So medication-induced weight gain is a huge issue. It’s dramatically under-recognized. I actually just saw a advertisement for Vraylar, which is a new antidepressant, and they’re big push on this and I was actually really, really happy to see this. Their big push is that it’s relatively weight neutral. So I think people have caught on that. A lot of the bipolar medications, a lot of the second generation antidepressants and some of the SSRI’s too, and some people not in everybody for sure can cause weight gain. It doesn’t mean you shouldn’t take them, just means you have to factor that into any decision you make about whether you should or shouldn’t be using that medication. So Paxil isn’t one that we see as much weight gain from as we see with maybe a Abilify or lithium or Risperidone, but it can cause weight gain in some people. It sounds like, in this circumstance, 30 pounds is a lot. So when I see 30 pounds, that’s usually medication induced, especially over a reasonable time period. You also have to ask yourself was it weight regain versus weight gain? Weight gain to me is from one highest weight to the next. Where weight regain is, I lost 15 pounds and then I gained 15 pounds back. Very different processes, very different causes. So the thing I’ve talked to you about with Paxil is that withdrawing from Paxil coming off Paxil, that is probably one of the hardest medications to wean yourself off of. And so. Whether you take it whether you don’t, you need a physician supervising this decision. I am not an SSRI expert or psychiatrist or anything like that. I don’t prescribe them. I don’t manage them, but I do know when a patient that I’m operating on is taking Paxil, I make sure they get Paxil. Post-op day one they’re getting their Paxil. I will not mess with that drug, because even a few days of stopping that medication can be really rough. Whatever you do, talk to your prescribing physician about this. If you are not taking it anymore, I’d be careful about restarting it. If you are taking it, you cannot just stop it. It can be rough. This is a tricky question, but be careful with this. These medications are not something that you should mess around with. You can’t just say Dr. Weiner has mentioned a Abillify on his podcast and that it causes weight gain. I’m going to stop taking it. You can’t just do that. You must talk to your prescribing physician. That disclaimer we have at the beginning of the podcast. That’s a real advice. Take it please. All right, what do we got next, sierra?
Sierra:
This one is from Margaret on our website. What supplements do you suggest?
Zoe:
First off I want to say I’m a very much a food first type of gal. I think that it’s-.
Dr. Weiner:
Eat your vitamins, don’t take your vitamins.
Zoe:
Exactly Like eating a variety of colors from fruits and vegetables. Of course, we want to try to get the majority of your nutrients in through Whole Foods first. There are situations that supplementation is very helpful, such as after surgery, after bariatric surgery that’s a big thing that we talk about being on a GLP-1 medication. If you are severely restricted in how much food you can eat, you are prone to developing deficiencies as well. I do think that having in those two scenarios having a quality multivitamin perhaps you may need an iron, perhaps you may need a calcium it really will depend on if you’ve had surgery, how much your medication is limiting your volume. For most people, if you aren’t in those other categories and you’re eating a nice variety of foods, you may not need a vitamin or any supplements. Most people are deficient in vitamin D. If you get blood work done and you’re low in vitamin D, then that’s definitely something to consider to increase. I think the word supplement can also include protein supplements. If you are struggling to reach your protein goals and you’re severely decreased in the volume you can take in, then adding a protein supplement to reach your protein goals can be helpful as well.
Dr. Weiner:
Which ones do you recommend? We sold in the office we used to sell Bariatric Advantage. We just recently switched to ProCare. What’s your thoughts? You’ve worked with both of them. There’s a lot of other ones out there. How do we decide? Why don’t you walk through some of our decision making for switching from Bariatric Advantage to ProCare?
Zoe:
Great. Well, I think a big piece of it is. We’re always trying to help our patients with the path of least resistance, and for a lot of people, budget is a barrier. I think that it’s very valid. I think we all want to try to save money.
Dr. Weiner:
You can spend half as much and get the same product.
Zoe:
Exactly. Specifically after bariatric surgery. We need to make sure you’re taking a bariatric specific vitamin, because the concentration of what you are getting in those vitamins are hundreds, sometimes even thousands for specific nutrients of times higher than what you get in a normal over the counter one a day, for example. If you are looking for a new bariatric vitamin, we do have the pro-care ones listed on our website. You can get a discount. If you are looking for maybe a nice backup high quality multivitamin or another kind of supplement that is not bariatric specific, we recommend the Thorne products, which we also have on our website as well, because they are so high quality and relatively affordable.
Dr. Weiner:
Yeah, there’s a big push in the bariatric literature about vitamin compliance. Rightfully so, especially the first few years for gastric bypass patients. Iron life long potentially. We talk all about compliance, nobody ever talks about cost.
Zoe:
Yeah, compliance and cost go hands in hands.
Dr. Weiner:
Of course they do. Of course they do. Yeah, the vitamins if their vitamins are 40, 50 bucks a month, most people well, not most people, but there’s a lot of people out there who say that’s just not in my budget, I’m not going to take them.
Zoe:
I also think it’s important to note that something that I like to talk about sometimes is we anticipate food costs going down. Right, If you get surgery, you’re eating out less, you know. Whatever Part of signing up for surgery is recognizing that maybe food costs go down, but your supplementation budget does need to go up.
Dr. Weiner:
Right? No, absolutely. I think that has to be part of the informed consent process. Here’s what having bariatric surgery costs. Yeah Right, I’ve talked about the economics of obesity. There’s one more component to it. But yeah, we recommend ProCare because we think they’re quality vitamins and they’re generally about half the price of most other vitamins.
Sierra:
Okay. Next question is from Janice, from our YouTube video, How to Lower your Set Point. I’ve been dieting four months, went vegan, lost eight pounds and just stopped. I think I need to lose 20 pounds more. It’s so discouraging to get on the scale every day at the same weight. Interesting video.
Zoe:
So there are a couple of things I want to address here. First off, vegan. If we’re talking about plant-based diet, we know that we promote and suggest that most people follow a mostly plant-based diet. Where I have a question, or where I maybe want some more information, is if you’re getting enough protein or if you’re eating the right variety of foods within the vegan diet. So that’s kind of a sub-fold question.
Dr. Weiner:
It’s not an easy question.
Zoe:
Yeah, no, absolutely, and so that would be something I would think through is okay. Are you getting everything that you need nutritionally via that vegan diet? Now the other piece that I want to address is we know that the scale is not always the best measure of success, because it is frustrating and most people are very emotionally attached to that number on the scale. I do not recommend for most people, I do not recommend stepping on the scale every day, and the reason why is because we see it becoming this obsessive behavior. We see it impacting your emotions for the day and oftentimes, your choices. Perhaps you step on that scale. It went up. You’re frustrated. Oh, I better skip breakfast today. Or, it goes down, Woohoo, I can treat myself extra with whatever. So if you’re finding yourself very emotionally attached and creating this obsessive relationship with that number on the scale, I recommend stop weighing as frequently and look more towards non-scale measures of success. So some of those things include how your clothes are fitting, perhaps if you are interested in doing circumference measurements or progress photos that can show change in body composition without seeing specifically what that number on the scale is. Other non-scale measures of success include improved lab work, maybe being your performance in your exercise, whether that’s walking further or lifting heavier or not needing to take a break walking up a flight of stairs. There are all of these really, really wonderful ways to see progress and celebrate your success that don’t include that number on the scale, and I recommend honing in on those If you feel as though you are quote quote doing everything right and that number not budging. Yeah, maybe reframing your mindset a bit.
Dr. Weiner:
Yeah, I think that’s interesting. I think, first of all, they’re vegan, but you know there’s a couple of different ways you can be vegan. Right?! Sierra, just for a second, Google this, “Are Oreos vegan, I think they are. So we’re having Sierra check this. I think Oreos are vegan. So yeah, so they’re safe to eat for vegans. We have confirmed that by Google. So my point is that just being vegan alone is not going to necessarily do it. So what exactly does that vegan diet look like? So that would be my first question here. But let’s say it is tight. They’re doing the animal, the plant-based protein, they’re minimizing their flour and gluten products and eating tons of fruits and vegetables and nuts and seeds and doing everything exactly the way they’d want, and they’re still stuck here. I think that’s where the pyramid comes in, and this is. We start with nutrition, and the truth is nutrition doesn’t fix every weight problem, and that’s one of the things that we just haven’t grasped as a society. We thought, well, if you could just get your eating right, you’ll figure this out. But it’s not necessarily true. You can eat a near-perfect diet. Our food chain is pretty polluted, so you can only eat off the food chain that we’ve got. You can’t just go off the grid into the wilderness and hunt and gather for your food. That’s just not realistic. So we got to eat the food we can, that is in front of us and we have to do our best with it. And so, once you’re doing the best with it, and my hunch is Janice is doing the best that she can, and she really can’t get much better than this. It’s time to move up the pyramid if you want to lose more weight, and that’s where the GLP-1’s come in. And again, I think we’re going to talk a lot this year about low-dose GLP-1’s in combination with nutrition, and this would be a perfect scenario for a low-dose GLP-1. Do you have to take it every week? Maybe you don’t have to take it every week. Maybe every two weeks, every three weeks. Again, this is something you’d have to work through with your prescribing physician. But this idea that here’s the med, you got to take it exactly the way it’s recommended and that’s the only way to take it and it’s the only way that’s safe. It’s not what we’re seeing in our practice, and so we work with our patients to come up with something safe, something sensible, that works in their life and gets them to their weight loss goals, and so this is a perfect scenario for moving up to that next step in the pyramid, to the GLP-1 meds.
Zoe:
Just trying to get that kick in the right direction.
Sierra:
Okay, Next question is from YouTube, Four things you need to know about the new GLP-1 weight loss medications from Razor. What about the risk of thyroid tumors and pancreatitis?
Dr. Weiner:
Okay, two separate questions here, really, so let’s take those one at a time. So question I ask every patient in my practice before we prescribe GLP-1 medications is do you have a family member that has died of thyroid cancer? So first of all, thyroid tumors in general are not very dangerous tumors, extremely survivable tumors. Very few people pass away, die from thyroid cancer. It’s one of the good cancers to have, if there’s such a thing.
Zoe:
You need to go in and remove that tumor.
Dr. Weiner:
Yeah, and it just doesn’t metastasize. It’s not aggressive, it doesn’t spread. There’s an exception to that it’s something called medullary thyroid cancer and that is almost 100% fatal. It’s a terrible, awful disease. It spreads rapidly throughout your body and almost everybody who develops it will get it. Now GLP-1 medications have been shown in animals to increase the risk of medullary thyroid cancer. So I’m not an animal scientist, but my suspicion is that whatever animal they study this in had a higher rate of medullary thyroid cancer than we see in the US in humans. The truth is, medullary thyroid cancer is a terrible, terrible disease, but thankfully an extremely rare one. I’ve probably asked this question to 500 people this past year and I think I’ve had one person think that they had, but then when we did some research it wasn’t, they didn’t have it, and so this is a very rare cancer, but in animal studies they showed an increased rate of medullary thyroid cancer. There’s never been any human studies to demonstrate this and we’ve been prescribing GLP-1 medications for 20 years now, going back to Byetta and Ozempic for about 10 years and really millions and tens of millions, hundreds of millions of prescriptions probably at this point, and we’re not seeing an increased risk of medullary thyroid cancer. There was originally some discussion about some of the less dangerous thyroid cancers, like papillary and follicular cancer, having increased rates of with GLP-1 meds. That hasn’t panned out either. I haven’t seen any science that really supports this. Now pancreatitis is a different issue. The rate of pancreatitis is about eight to nine times higher if you take GLP-1 medications. So pancreatitis is an organ that is at the very core of you and it kind of sits within the intestines, kind of somewhere between the front of your abdomen and the back and your back, and it’s where our insulin’s made, it’s where our digestive enzymes are made. And taking GLP-1 medications increases your risk of developing pancreatitis again by eight or nine times. Now pancreatitis can be terrible. It can be one of the worst diseases you could ever have. It can take someone who’s totally healthy and fine and they can be on the verge of dying within a few days. So that, thankfully, is about as rare as medullary thyroid cancer. The overwhelming majority of cases of pancreatitis are what are called self-limited, meaning the pancreas gets inflamed. Will measure the values in your blood test that show that there’s been some release of some of the pancreatic enzymes in your bloodstream. We might even get a CAT scan and show a little bit of inflammation and the treatment for that is just kind of take it easy with what you’re eating and it’ll pass with time. So what we’re seeing with the GLP-1 meds and even in our practice we really haven’t seen that much of it is the milder forms of pancreatitis, and the truth is probably all of us at some point have had pancreatitis from a virus or something we thought was a GI flu, but it was probably pancreatitis and so it’s something that we see.
Zoe:
So what is the mechanism of action? Why do the medications increase that pancreatitis? Does it have to do with the insulin?
Dr. Weiner:
It must have to do with the insulin which is released in the islet cells in the pancreas. I don’t know. It could have something to do with the acinar cells, which are what release the digestive enzymes. I’ve kind of given up on being a scientist and kind of understanding every little thing and why it happens. First, because we understand so little that if you’re going to really have a complete and detailed grasp on every single question about how the body works, it pretty much can be the only thing you do.
Zoe:
You can’t see patients, you can’t operate.
Dr. Weiner:
So I’m a clinician. I see people all day long. I operate, that’s what I do. So I don’t know why it does. I know that it does and I think that that is really how we can make decisions that impact people. How it works, that’s for the scientists to figure out. If there’s maybe a medication or something that can reduce the risk of it. That’s not my role. My role in life is to help patients manage these medications, go through bariatric surgery safely, and so we see that when you take these medications, it increases your risk and it means this is one of the risks. We see it more with some forms compared to others. So actually, the one that I think has one of the higher rates of pancreatitis is Trulicity, and Trulicity is probably one of the worst GLP ones when it comes to weight loss, it doesn’t give all that great results anyway. No, it’s really kind of crappy weight loss with trulicity. So this is something we’ll have to kind of work out over time, but there definitely is an increased risk of pancreatitis. Now, is it something that’s going to significantly impact your life? Most likely not. Is it something that may result in you having to stop the medication? It might be. It might be and I think we may see that in the years to come that this may be something that kind of limits people’s ability to tolerate the medications over the long run. Well, I think that wraps things up for us. Episode seven I think we’ve made a commitment. We’re doing this for the year for 2024. We’re also taking little segments from this and putting them out on Instagram and TikTok. So if you like that, you can follow us on those. We kind of dress them up a little bit more. We’ve got some good video editors doing some work for us. But, yeah, I think that wraps up our show.
Zoe:
Yeah, thanks for listening and we’ll see you next time.
