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Episode 14 kicks off with a Kohlrabi recipe from Dr. Weiner and continues with tales of variable reactions to GLP-1 medications like Ozempic, the conundrum of weight regain post-VSG surgery, and the intricate dance of GLP-1 dosing. Join our circle as we converse on genetic factors influencing treatment efficacy, the alternatives for the non-responders, and the art of maintaining an injury-free fitness routine, and the all-too-common hidden sugars lurking in protein bars.

Facing obesity is an odyssey of both heartache and hope. Our guest, Chrisse opens up about her own struggles with obesity, the back injury that compounded it, and the undulating path of weight management post-bariatric surgery. She also talks about the emotional weight of obesity that often escapes the empathy afforded to other conditions. Together, we underscore the vital role of community and the unyielding spirit necessary to navigate these turbulent waters.

Brace yourself for life-altering insights as Zoe, our personal trainer and registered dietitian, bestows her wisdom on both nutrition and exercise, offering actionable advice to steer clear of injuries and elevate your fitness journey. As we marvel at the athletic longevity of the legendary Tom Brady, we also tackle the pressing issue of obesity medication access, dissecting the hurdles faced by patients and healthcare providers alike. This episode is a heartfelt symphony of health and wellness, aiming to change the narrative around the pursuit of a healthier life.

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Zoë: 0:33

Welcome back to the Pound of Cure Weight Loss podcast, episode 14: No-Zempic? No Thank You!


Dr. Weiner: 0:39

So, Zoë, I made the most delicious thing for dinner last night. Trader Joe’s has these Kohlrabi noodles. Kohlrabi is like this solid, almost like a root green vegetable, super healthy, super nutrient-dense. They cut it into little slivers as a pasta replacement. You put that in the air fryer, just a tiny bit of olive oil, and then you put pesto on it. Everything’s better with pesto, and pesto is Pound of Cure-ish. It’s probably a little heavy on the olive oil for what we recommend for weight loss, but olive oil is one of those things that’s maybe not the best for weight loss but is definitely not an unhealthy food. I mean, it’s good for your heart and there are some health benefits from olive oil, but it can reduce your ability to lose weight a little bit. But it was so delicious. 


Zoë: 1:31

So, what was the texture like? Was it crispy because it was in the air fryer, or was it more noodly?


Dr. Weiner: 1:35

It was a little, kind of, yeah, it was more crispy, almost not quite like French fries, in that it wasn’t kind of doughy, but it was a little greener and fresher and it did have a bit of crisp to it. Yeah, so the air fryer worked great for the Kohlrabi. You can steam it too. It comes right in the bag, and you can steam it. But I feel like when I’ve done Kohlrabi in the past, it gets soupy and wet. My wife says over very frequently, she hates wet food, which I kind of get.


Zoë: 2:09

Yeah, that’s fine. It’s a new food descriptor.


Dr. Weiner: 2:12

Yeah. All right, enough about our family dinners. What do we have on the show for today?


Zoë: 2:17

Alright. On our show today, we have “What happens when you don’t respond to Ozempic,” our patient Chrisse, who I’m super excited to hear from, her experience with weight regain after VSG, and the cost-effectiveness of her dosing strategy. So good stuff is coming for that. In my nutrition segment, “How to Avoid Injury During Exercise,” we’re also going to be discussing that V-shaped weight loss curve after VSG, weight loss surgery success genes, and then also going to be talking about protein bars and sugar content.


Dr. Weiner: 2:49

Yes, I think we have a good show for you. Our first segment is in the news, and this comes from The Atlantic. The first thing I want to do is give a plug to the author, Yasmin Tyag. This is the second episode that she’s written that we’ve featured. Our first one was an episode about a meat snack, where we discussed weight loss, surgery, and medications together. It really illustrated exactly what we do in our practice, where we combine therapies. I find that her articles are, number one, very scientifically accurate and really not prone to a lot of the judgment and bias that we see in most coverage on medications or bariatric surgery.


So this article is called “Ozempic Can Turn Into No Zempic,” and it’s absolutely worth a read, especially if you’re on a GLP-1 medication and the results didn’t turn out the way you expected. You’re going to hear from Chrisse, our patient, and she’s going to tell a fantastic story of how her body responded so positively to this medication. And there are definitely lots and lots of people out there, but not everyone. With Ozempic, if you look at the original trials, we saw a 15% average total body weight loss. If you’re 200 pounds, that’s about 30 pounds. However, 13.6% of people in the trial lost less than 5% of their body weight, and I think that’s a really important thing about these medications. Just like with weight loss surgery, just like with weight loss through nutrition, there’s variability. Some people lose more, and some people lose less.


With Tirzepatide, we saw 21% total body weight loss, and in the Surmount trial, 15% lost less than 5%. So, even though Tirzepatide is kind of a better drug than Ozempic when it comes to weight loss, we actually saw a slightly higher rate of poor weight loss response, and that just shows you that there’s a small group of patients, about 14-15%, who really don’t respond. So why is that? There are a lot of different thoughts about that. I think that probably the most accurate one is that you have to think about the physiology of these medications. So our body has receptors, and receptors are just proteins that we code from our DNA, and your GLP-1 receptor and my GLP-1 receptor might be a little different. Most likely, we have different genes, and those proteins are going to kind of take on a slightly different shape.


Now keep in mind how these medications work. Normally, the actual GLP-1 molecule binds to the receptor, and it’s released very quickly. That’s why just giving someone GLP-1 doesn’t work because it only lasts for a few minutes. The medications have a very long half-life, and so they bind to the receptor. They stay bound to the receptor for a much longer time. It’s a much greater affinity. Now, if we have different receptors, that drug may bind differently to your receptor than it does to mine, and so that difference is almost like that lock in a key analogy where some people’s receptors kind of bind tightly to the medicine and others don’t.


Now what we don’t know is: if you don’t respond to Ozempic, do you respond to Tirzepatide? I personally think it’s absolutely worth a try. I’ve had a lot of patients who’ve had great responses with one drug and then really responded well to the other drug. That’s something to keep in mind as well. It might be that your receptor works better with Ozempic than it does with Tirzepatide. I think there’s another piece of this, though, and that’s patient tolerance. We see two reasons why people don’t respond or don’t lose a lot of weight on these medications. The first is what I talked about. It doesn’t work. They take the medicine, they don’t really have much response, and they don’t lose much weight. The second is that they don’t tolerate it. They take it. They have too many side effects; it’s too unpleasant. They’re like, “Get me off this medicine; I don’t want to take it.”


I think we can often still help that group find success with some creative dosing strategies. If you follow the FDA or the drug recommendation for how to dose them, it’s not going to work. You have to get creative in this group. We have had a lot of patients who initially just didn’t like the medicine at all, but by adjusting the dosing strategy and the diet as well, we were able to get them to tolerate it. I think this really puts us back on the idea that there’s this treatment period. The base is nutrition, and then we’ll use GLP-1 medications. Weight loss surgery sits at the top, and we use all of those therapies as we see fit to help people battle the disease of obesity.


Zoë: 7:36

I think it also just goes to show how individualized this is, just like with nutrition changes, just like with medication management. Having a team of support to help you navigate that individual case is really important, because we can help you identify that maybe you don’t respond to this one, but using a different medication or a different dosing strategy, like you were mentioning, we may be able to find a way.


Dr. Weiner: 8:04

You really need expertise at all levels of the pyramid. You need expertise in nutrition. That’s where you come in. Expertise in the medications — that’s where me, Diedre, and Bether, or nurse practitioners, come in, and then expertise in the surgery. It’s all three of those together that we find that we’re able to help 95% of people successfully battle this disease, and I think that’s amazing. At no point in my career to see success like what we’re seeing right now. Let’s go to our patient story. This is our first remote patient. Everyone else has kind of joined us in the office. These patients are, you know, from out of state. They’re joining us remotely. I’m a little nervous about the technology, but let’s see how it goes. So why don’t you introduce Chrisse?


Zoë: 8:47

All right, let’s hear from Chrisse. I’m super excited to have her on, and Chrisse’s been a patient for quite a while. Did you know her when you lived in Michigan?


Dr. Weiner: 8:56

I didn’t, actually. She kind of heard of me through the grapevine in Michigan, and I may have met with her at one point, very briefly, I think, way back then, and she kind of tracked me down again and joined our nutrition program once we were here and set up in Arizona.


Zoë: 9:11

Okay, awesome. Let’s hear from Chrisse. All right, now we have our guest, Chrisse. Welcome! I’m so glad you’re here with us.


Dr. Weiner: 9:18

Thanks for coming, Chrisse. Why don’t you share your weight loss story with us? Your starting weight, the things you’ve done to lose weight, and where it’s worked and where it hasn’t.


Chrisse: 9:28

Sure, you know I struggled with weight even in my childhood. I was a kid who would hide food. That started really early, like six or seven years old. I would hide food and hoard food. My parents did not really know what I was doing. I remember even in my teenage years that my dad actually mentioned to me that he would see a ton of food wrappers, even in the back of my car, and things like that. So I really struggled with food and weight all through childhood. But I was also very, very active, and I really thought that as active as I was, my body probably just was not responding. Kind of an abnormal range of what you might see in a normal person. Even though I was an avid swimmer, and I remember, you know, looking at my body against other people’s bodies and realizing I probably have an issue and kind of having that ingrained in me. And then, you know, teenagers into their 20s and early 30s. It’s really every single diet. It was weight watchers, it was Atkins, which flowed naturally into keto. I did paleo for a really long time in adulthood and saw some results there, but I really could not get out of the 200s with weight gain, and my highest weight was just over 300 pounds. So it really became a very, very significant issue for me. And you couple that with a ton of inflammatory responses, and I was just in a lot of trouble, and it was very long-lasting and very broad-reaching. It took me to some bad places, health-wise, for sure.


Dr. Weiner: 11:09

You ultimately decided to have weight loss surgery.


Chrisse: 11:11

I did so — a friend of mine, actually did it. I heard a rumor that she might have had weight-loss surgery, and her results were just incredible. So I just called her, and I said, “Hey, you know, you know my situation. Would you be honest with me? Did this happen? Because if it happens, I have about 300 questions for you.” And she was honest, and she was so generous with her time, and it really helped me get over any kind of hump I might have had or any kind of concern I might have had. I just had a laundry list of things I really wanted to cure for myself. I had a wish list for myself, and I keep it on my phone because I really consider what has happened to me to be a massive gift. But you know, when you look at a list like, I really would like to wear short hair or wear my hair up in a ponytail where you can see my whole  face, I want to be able to do something as simple as put my pants on without feeling like I’m going to pass out. I want to be able to tie my shoes without getting the pounding pressure in my face. I want to be able to ride a bike. These are very simple things, you know. Your humanity starts to get stricter in some ways at higher weights, and there’s no judgment about that. I’ve lived through that myself. But it does not come without emotional repercussions, for sure.


Dr. Weiner: 12:35

Yeah, I think everything you’ve said, all the limitations you’ve had about putting on your pants and riding your bike, really, as I was listening to them, are symptoms. You know, those are symptoms you’re experiencing as a result of a disease, and the way you just described that to me was just, it was almost like clinical in a way, and that if you were talking about heart failure or having had a stroke, God forbid, or some other medical condition and the way that it limited your daily life, we would all be like, “Oh, we’re so sad for you, it must be so hard for you.” With obesity, you have all those symptoms and all those restrictions, but empathy is often fleeting.


Chrisse: 13:17

Oh, it’s not often fleeting; it’s just coupled with massive judgment. I am not a doctor, obviously, but I have lived in this for my whole life, and I have really researched. I have tried incredibly hard for so many years. I believe that there might be two different pools of obesity. I really believe that there is medical obesity, where you need intervention to get that help, and there’s probably also habitual obesity. I mean, we go to college, eat too much pizza, come over home over the summer, get really active again, and that goes away. So I think that there really are two pools, or potentially more. I just knew that I needed some medical help. I also had a significant back injury and a failed back surgery, which led me to even more problems, and I’m certain that some of that inflammatory response really played into my developing back issues and then having a very long run of trying to get through that.


Dr. Weiner: 15:11

Injury is one of the most common causes of weight gain. I’ve heard this story many times: They were told to exercise very vigorously, well beyond what their physical capacity was, and they got injured as a result of that. And, of course, when you get injured, you gain more weight.


Chrisse: 15:33

It’s funny that you say that. One of the first times that my back injury surfaced, I was actually on a pulling machine in a gym with a trainer who was not educated enough to be training. Maybe anyone, but certainly someone at my weight with my issues, without really understanding it. And that was really the first time that that lower back really kicked in for me, and, honestly, even after weight loss surgery, that’s really how it emerged again because I think the damage was already done and then I had some regain, even after the weight loss surgery that occurred after that. During my weight loss surgery, I really leaned into my sleeve. I am one of those people who, you know, when I felt that restriction, I was celebrating it, and I’ve studied a lot. I still stay on all of the boards, I stay really active in support groups, and I do see people react after surgery. It’s almost a shock that you can’t eat, and people say, “I just don’t even want to cook because I can only eat a few bites,” and I was one of the people saying, “I can only eat a few bites,” almost celebrating like that. At my high weight, 300.4 was my high weight, and my surgery weight in 2017 was 277. I ended up losing down to, like, my stabilized loss was right around 143, 144. And then I had a significant back injury that led to a very long run of major steroids, a ton of different medications — steroids making you crave food, craving carbs, all the inflammation that comes back. And from that 144 point, I find myself back at 199. I remember clinging to that, like 199.9. Don’t cross back over. Stay in Wonderland. Stay in Wonderland. But it was really, really difficult to get back there. Emotionally, I was just wondering how I was going to kind of land on the right side of my surgery again.


Dr. Weiner: 17:37

Yeah, how soon was it after your surgery that you injured your back and had to take steroids?


Chrisse: 17:42

So the injury, the final straw of the injury, happened in late 2019 or early 2020. So it was a couple of years, two years and a couple of months, and again, I’d been stable for a while, but it really threw me almost immediately after those meds started. And, very thankfully, after a number of months, I was able to find a surgeon who could help me. So the back injury was cured, but I could not get my weight back on track. I almost re-stabilized, but, as you know, I lost almost 200 pounds. And I was with you guys. I joined the support groups. I was going to nutrition classes. I was coming in. I loved the support there. But I remember there was one day, Dr. Weiner, that it was one of your groups that you joined, and you were just asking people in the group, like, “What’s your story? What’s happening?” And you asked me specifically, like, tell me, tell me what’s going on. And I let you know those details. And you said, “Listen, you have got to get this weight back off, and you have to do it now because your set point is going to set in at that weight and your struggle is going to multiply to get back down,” and it was at that point really where you mentioned Wegovy to me, and I was super excited to hear that there might be a possibility for me.


Dr. Weiner: 19:05

So you started Wegovy, and I thought this was actually kind of a classic scenario where these meds are appropriate because it was, you know, to some degree, I think, like you got to fight fire with fire and you gain weight from medications, and so if we use a medication to help with weight loss, sometimes that does make some sense. And so we got you on Wegovy. I think you ended up getting it from a local provider, right? Did you talk to your PCP about it?


Chrisse: 19:31

Yeah, I did. I went back to my primary care because it was new and my primary care has been with me for years, and she was incredibly supportive of my weight loss surgery. She had partnered with me following weight loss surgery, so I reached out. I really wanted a strong support system around me. I’m very lucky to have an incredibly supportive husband. I have doctors around me who have been supportive. And she actually was not familiar with Wegovy at the time and she said “You know what, let me do a couple days of research and let’s talk again in a couple days and I’ll come back with a recommendation.” And she came back and she said, “Chrisse, do it.” She said “Everything in your history and this medication go together so well. I think you’re going to be incredibly successful. Trust him and do it.” And you know I did the normal ramp up on the Wegovy, the 0.5 to the 1, to the 1.7 to the, you know, with 0.25, I guess, starting dose. And within one hour of my first dose, I knew my head was right again. It was so fast. That day. I remember talking to Zoë. I think it was later that week, and I said you would not believe it, but within hours my head was right. It took away every craving I was having. It was completely quiet again, like I was right after surgery. All of the food voices were gone; everything was quiet again. It was just such a sigh of relief, and I had the normal kind of re-hungriness that you get towards the end of those low doses. But again, I just really leaned into it. I stayed on track with the ramp-ups monthly and just saw a ton of success with them. So during that time, I was on a normal dosing structure with Wegovy. I lost not only back down to my post-surgery weight of that 144 point, but I actually now kind of stabilize between 131 and 133 somewhere in there, and I’ve been very, very stable for a couple of years now at this level where, you know, that set point conversation you had with me really resonated, and I feel like that is what we’ve achieved. It’s this new set point where my body just kind of stays here and is super happy, and as you know, I’m not on a normal dosing structure.


Dr. Weiner: 21:55

No, so what are you doing now with Wegovy? How much are you taking? How are you working it out? How are you getting it?


Chrisse: 22:02

So I am actually one of the people who has to do cash pay. But you and I really worked through some strategies. You know me saying, “Okay, the week comes up and I’m supposed to redose, but I’m really not hungry.” And then I redose, and I’m getting all of the negative side effects of it, and I feel like I could go longer. And so it was like, “Well, can you get to two weeks? Okay, well, can you get to three weeks?” And I remember the conversation that you and I had where you said, “Chrisse, dose when you get hungry; when that happens, when that kind of inner dialogue starts again — not real hunger but head hunger — when that head hunger kicks back in, dose.” And now I really can go between three and a half and four weeks very easily. I mean, this last run was four weeks and three days in between dosing. I am at my highest dose right now, but post-holidays, I needed just a little bit of a bump. But even this last round, when I went for four weeks and three days and then dosed again, I can tell that it’s too high again, and I need to drop back down to the 1.7. So I’ve been very, very successful at stretching the doses. You really lean into nutrition and stay on a plan. You don’t stretch how much you’re eating. It really helps to stretch the days in between doses. I’ve been super successful that way.


Dr. Weiner: 23:26

Yeah, I think it minimizes the side effects, and that is also what you said. It really emphasizes nutrition. You can’t pull that off if you’re not putting in the hard work on the nutrition side. I know you and Zoë have worked a lot on that. I think I would put as a disclaimer that you certainly have an alternate dosing strategy, but this is something you and I came up with together. This is not something you kind of picked up at some compounding pharmacy and started trying to work through it on your own. I think that’s really the key: you have to work with your prescriber to come up with something that works for you but is also within the confines of what’s medically safe, because I do get some questions sometimes from people and say, “Hey, I came up with this idea,” and I’m like, “No, don’t do that; you’ll be sick for a week if you do that.” And so you have to be very careful with this. You kind of slowly and organically came up with this approach, and this is what works for Chrisse. This is not necessarily a standard approach for everybody, and that’s what I’m finding is that we have to, just like with nutrition, work for individualized nutritional plans for people based on their lifestyle and other limiting factors. We have to come up with dosing strategies for people as well.


Chrisse: 24:40

But, Dr. Weiner, this is why you and your team are changing people’s lives. There is such a trend in the industry for surgeons to kind of herd people in. You get the surgery, and you leave. There’s no real support. People have very basic questions following surgery that always surprise me that they’re asking because we are lacking in support in this field in such a big way. And I know I tell you every time I see you. But the work you are doing is changing people’s lives. It’s giving people a life who haven’t really had one. It’s not that I wasn’t living, but dealing with the emotional side effects of obesity every minute of every day is not an understatement. It severely impairs you as a human, and I cannot thank you and your team enough for the work you’re doing. The partnership that you offer, the consistent support, and the creative ways that you are supporting me are making a huge difference in my life. I know it is doing that for other people. I encourage anyone I come across who has questions to please go watch the videos and join the groups. It is life-changing. It has been for me, and I am so grateful to you and your team.


Dr. Weiner: 25:59

Thank you. We are very grateful for you. I think that’s a great little plug to join the nutrition program, don’t you think? So if you’re out there and you want to join our nutrition program, it’s open to everybody. I have support groups. Zoë has support groups. Our peer leaders have support groups. Chrisse, we are so grateful that you came on the show and shared your story. I think it’s fantastic. We’re so happy for you to see how much you’ve transformed your life with your surgery, the medications, and your deep commitment to nutrition and lifestyle changes. So we’re happy to see you on this path and really see a lot of good things for you in the future.


Chrisse: 26:36

Thank you for giving me my life back. Thank you, thank you, thank you.


Dr. Weiner: 26:41

Her story of her back injury after her surgery, which resulted in steroid use and a lot of her weight gain, might be perceived by many as something inevitable or just an unfortunate event, but I’m not sure I view it that way. Zoë, you’re a personal trainer as well as a registered dietitian. Talk to us a little bit about what you can do to avoid injury during exercise.


Zoë: 27:04

Absolutely. Well, I have a couple of thoughts, but I have three main points that I think I’ll try to keep concise here. So the first one is that if you are new, you don’t want to go from exercising zero days a week to being in the gym six days a week. You’re not going to go from 0 to 100 that fast, and so really meeting yourself where you’re at and slowly increasing is important. But a big recommendation would be to utilize those kinds of introductory free personal training sessions that a lot of gyms have, not necessarily to get a really intense training session out of, but to say, “Hey, can you orient me to the equipment?” so that you learn how to use the equipment and the weights safely, and that sort of thing, so you know what you’re doing. Then, that way, you can start slow and build up. Another thing is working on your flexibility and doing some active warm-ups beforehand, stretching afterwards — those sorts of things to really make sure that your joints and your muscles are nice and warmed up so that you’re not making yourself prone to injury. And then the last one actually has to do with nutrition. So I know so many people who exercise in a fasted state because they think or they’ve heard that it burns more fat, and I actually wrote a paper in college on this. I did some research, like a review of the research, but there’s not enough significant data to show that. But what training or working out fasted can do is make you feel more tired, lower your energy, and make you more susceptible to injury. If you are dragging yourself through the workout and your form is getting sloppy because you haven’t fueled properly beforehand, then that’s going to make you more prone to injury as well.


Dr. Weiner: 29:02

Yeah, the flexibility thing. I’m a Michigan guy and, obviously, a huge Tom Brady fan. He was a quarterback at the University of Michigan back when I was in medical school there. So he had a 20-plus-year career in the NFL. I mean, being an NFL quarterback, that’s like the most injury-prone job there is. He didn’t do a ton of weightlifting; he focused primarily on flexibility. That was like the biggest part of his training: flexibility and becoming more resilient. He thought that’s what made him most resistant to injury.


Zoë: 29:35


Wow, that’s really fascinating. Like if you get sacked and your legs go over your head and you’re bouncing up in the splits. I mean, that’s a good thing, yeah.


Dr. Weiner: 29:45

Yeah, I looked at that, and I’m a few years older than him, but not that many years older than him. And for the longest time, I’m like, if I tripped and fell while walking, it would really mess me up. And this guy’s out there being chased by 300-pound 20-year-olds and taking hits. I mean, it was really remarkable. But those are great points, and I think the most important thing is that injury causes weight gain, and if you exercise and become injured, it’s actually bad that you even chose to exercise. You’d be better off if you didn’t exercise. And that doesn’t mean you shouldn’t exercise. It means make sure when you’re exercising that you’re taking all the steps that Zoë recommended to prevent injury because that would be very damaging, and we heard from Chrisse just how much that can hurt.


All right, so let’s move on to the economics of obesity. So this topic I want to talk about is: Where is all the Wegovy? We had one of the Wegovy reps come in right away, I think it was early 2023, and they said, “Listen, it’s only going to be a few more months, and then this backorder stuff is going to be old.” We’re now a year later, and we’ve seen absolutely no let-out. I think the first thing is to recognize that there is a remarkable demand, so lots and lots of people want it, but it has been on backorder for over a year. There are almost none of the lowest three doses. So the way they’ve restricted this is that they’ve taken those entry doses, the 0.25 milligram, the 0.5 milligram, and the 1 milligram, and they’ve restricted manufacturing of it so that only people who are already on the higher doses can get the medication.


There was a quote, and I really related to this quote in an article I read recently, and it’s actually from Michigan Medicine, and it’s from Dr. Andrew Craftson, who’s a clinical associate professor in the Division of Metabolism and Endocrinology and Diabetes, and he said, “It’s created this living hell.” And I think Sierra, our office manager, can share that thought — that patients are incredibly frustrated with their inability to get it. We can write the scripts, we finally get it prior to departure, and then people are running all over town trying to get this medication.


But Novo Nordisk, which is the manufacturer of Wegovy, has invested $11 billion, which is probably about two months of profit for them, into the investment in manufacturing. They doubled the availability of manufacturing these lower doses. So far, they’ve served one million patients. So there’s been one million people in the US since 2021, when it was released, who’ve been able to get the medication. The PBMs, the pharmacy benefit managers, who I’ve talked about in the past, who are generally this unscrupulous group that profits extraordinarily over high drug costs, have set lower reimbursements for the pharmacies, and that’s discouraged a lot of the pharmacies from carrying these medications, and so that’s creating a lot of push and pull as well.


So when we place all of these constraints on the pricing of the medication and make it overly complex, we generally get things like shortages and a lot of the problems that we’re facing right now. Even with this shortage, the drugs are incredibly profitable for Novo Nordisk. The GLP-1 medications, which are primarily going to be Ozempic and Wegovy for them, accounted for 61% of Novo’s $7.9 billion in revenue in the last quarter.


So I think the question that’s on everybody’s mind is, “What about Ozempic and compounded semaglutide?” So if you can’t get Wegovy, this is essentially the same drug. Ozempic has become almost impossible to get if you’re not diabetic. All of the loopholes we’ve been using over the years to get patients approved for these medications have been shut down. If you have diabetes and your medical policy and your diabetes fit what your medical policy criteria are, we can get you Ozempic. If it doesn’t, you can’t get Ozempic unless you can self-pay for it.


The compounded semaglutide we’ve talked about in the past. We don’t recommend or prescribe compounded medications. We think that it’s very unclear whether they’re safe or not. Pretty much every single medical organization that knows anything about prescribing in the pharmacy supply chain has recommended against the use of compounded drugs. We do also think that these are going to disappear as Novo Nordisk and Eli Lilly will begin to go after and defend their patent, which, quite frankly, they have a legal right to do. So we’re hopeful that sometime in 2024, we’re going to start to see more Wegovy and have more patients get access to it, and this increase in manufacturing will come through. Then I think we should. So there’s good news on the horizon for access to Wegovy.


Zoë: 34:37

All right. So let’s go ahead and hear from our followers, the listeners, and the patients who are submitting questions. I actually had somebody who, in one of my nutrition sessions the other day, said you’ve answered two of my questions so far on the podcast. I mean, that’s great. Keep submitting them. So if you submit a question, maybe we’ll be able to get to it. So, Sierra, what do we’ve got today?


Sierra: 35:02

First question: Hello, I’m loving the new podcast. Long-time Pound of Cure follower. I’m a 37-year-old male. The starting weight was 300 pounds. I had a VSG in October 2022 at 280 pounds. My lowest weight post-surgery was 200 pounds, and I am currently 220 pounds. I consider my surgery a great success. Over the past six months, I’ve been consistently gaining two pounds per month. I haven’t really had a stable post-surgery weight. I’m staying very active about three days a week, weightlifting, and two days a week utilizing some type of fun cardio. I am probably 80% adherent to the metabolic reset diet. I would like to see my weight stabilize below 200 pounds. What is the best course of action? Improve diet adherence, investigate GLP-1, and change my exercise routine. What do you recommend?


Dr. Weiner: 35:52

Zoë, let’s talk about what you’d recommend on the nutrition and exercise front.


Zoë: 35:57

Well, It sounds like he’s got a great routine of weight training, maybe depending on how many are just that neat that you’ve talked about before, the non-exercise activity thermogenesis. If you’re sitting down all day, perhaps there’s an area of opportunity to get up and go for a little bit more walks and that sort of thing. But we don’t know that because we haven’t gotten that information. 80% of those adherents to the metabolic reset diet go into that 80/20 rule that I think I’ve talked about before on the podcast. Obviously, without digging into his day-to-day nutrition, everybody has room for improvement. However, it sounds like he’s been doing a pretty damn good job.


Dr. Weiner: 36:38

I think 80% is pretty good. The idea is that you have to be 100% compliant, and by going from 80% to 100%, you’re going to get a little bit of results. But I don’t know that you’re going to change this course. It might go, instead of two pounds a month, to one and a half pounds a month, or something along those lines. I think we’re seeing something that we just unfortunately see way too often. I’m grateful, at least, that I’m seeing more and more patients coming in who understand that weight gain after sleeve is very common. We’ve kind of made it like this taboo topic, like you can’t ever say, “Oh, my bariatric surgery didn’t work the way I wanted,” because you’ve gone through this incredible thing. You’ve given up a part of your stomach with a sleeve, had major abdominal surgery, and it didn’t quite work out the way you wanted it. And so I think that it’s important to recognize that, with a sleeve, the medications for most people are part of the equation. And you know we heard from Chrisse about her story and how much adding the meds added, how it brought back the function of the sleeve, that kind of set point memory, almost where it was like, “Oh, you had a sleeve, let me help you back to where you were.” And I just think that’s part of the deal with sleeves for most people, unfortunately knowing that going in is important, and I have that conversation with every prospective bariatric surgery patient now and say, “If you want a sleeve, let’s also talk about the meds, because it’s probably going to be part of the plan,” and I think it’s important for us to embrace that because it’s a scientific reality. It’s not that somehow sleeve patients are less compliant than bypass patients. It’s that a bypass has less weight gain, and we have to accept that and educate people so that you can make the best decision for yourself going into it. I think this person should be exploring the medications.


Zoë: 38:43

Yeah, I thought you were going to say that. I didn’t want to say it because I’m not a doctor. It sounds like a perfect opportunity for the GLP-1.


Dr. Weiner: 38:54

That’s what works. Yeah, all right. So what do we have next?


Sierra: 39:01

Okay, next question: Hello, I will be having a gastric bypass in a couple of months. I’ve heard you mention in older videos that a gene has been identified that determines how much weight you will lose with the surgery. At the time you made the videos, maybe six years ago, you said that a commercial test for the gene was not available at that time. Is there one available now? I would really like to know if I am genetically programmed to lose less weight than average or if I will be a super loser.


Dr. Weiner: 39:29

Yeah, being a super loser in the bariatric space is a good thing. I think other terms that might not be the most friendly can be used to refer to somebody. So the answer is no; there’s been absolutely zero progress on this, unfortunately. My suspicion is that it’s because it’s not one gene but many, and I think we’re seeing this as we do more and more research that there’s definitely a familial component. We see this over and over again. If I see a sibling, a child, or a parent of one of my successful patients, I have a hunch that this person’s also going to be successful. I’ll often tailor my procedure recommendations based on family members’ success or lack of success with different procedures. But we still don’t have that, and in all honesty, I think this line of discussion has kind of decreased. It would be great if we could make predictions for people about it. You can use the tool on our website. We do have an outcome predictor tool. I think that the bell curve is a little tighter for a gastric bypass, meaning we’d see patients kind of fall within a smaller range of weights after surgery; with a sleeve, we see a little wider range, but now with the meds, the sleeve, maybe we may be seeing that tighten up a little bit. So I think life is filled with uncertainty. But with weight loss surgery, there is some risk involved with the procedure. There’s some risk involved in the fact that you’re not going to reach the level of success that you might hope for, but in general, the odds are very much in your favor of proceeding with either of these surgeries, whether you proceed with a gastric bypass or a sleeve with the intent of combining it with the medications. I think now with the GLP-1 medications, we’re seeing much more frequent success, and we’re seeing fewer problems with the way we gain because it’s treatable.


Sierra: 41:19

Okay, final question here from Nick. This is from our website: How do you get high amounts of protein without protein shakes and bars? I buy bars and shakes that have zero to one gram of sugar. Are these still acceptable?


Zoë: 41:33

So, I mean, zero to one gram of sugar? Yeah, that’s great. But we know that protein bars are obviously super processed, so there are going to be a lot of artificial sweeteners, a huge ingredient list, and so in a pinch, can you keep a protein bar in the car, in your backpack, or whatever? Yes, I would recommend the RX bars. The reason I like that is because the ingredient list is super short. It’s just peanuts, egg whites, and dates, and it’s all whole food. So it’s really great. You know, it’s a little chewy, but that’s great. You get a little workout, a little mouth workout in. So, you know, obviously, our goal is to reach your protein goals through as much whole, real, unprocessed food as possible. If you’re struggling, volume-wise, to get that protein in, then maybe try more small, frequent meals throughout the day. I like to call them mini-meals with protein in them. Having a smoothie is a great way to add a bunch of protein. But ultimately, yeah, zero to one gram of sugar, that’s great, but think about all those other processed ingredients in there. Maybe check out the RX bars and try to get as much of your protein in through whole foods as possible. You know you have to be your own self-advocate. You have to be your own nutrition detective. Read that ingredient list, read the nutrition facts label, and if you need help and support doing so, then definitely come and join our nutrition program, and I’m happy to help.


Dr. Weiner: 43:02.

Yeah, alright, another great show, Zoë. Fantastic; we’ll see everybody next time.

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What Your Doctor Really Thinks About Your WeightEpisode 15 Thumbnail - Medicare Disadvantage Plans