Episode 21 of The Pound of Cure Weight Loss podcast is titled, Vial Denial and the GLP-1 Shortage. The name comes from our Economics of Obesity segment where we discuss the GLP-1 shortage and how it’s caused by the inability to procure injector pens. Canada recognized this issue a while back and allowed pharmaceutical companies to use single dose vials instead of injector pens. So why aren’t we using single dose vials in the United States? I have some opinions about it.
Our In the News segment comes from an article in Reuters about how Viking Therapeutics is developing a weight loss medication that can be taken orally. The Medication is similar to Mounjaro and Zepbound in that it is both a GLP-1 and a GIP and the initial studies show better weight loss with more responders than Ozempic, Wegovy, Mounjaro, and Zepbound in the injectable version. Is the oral version going to be as effective? Tune in to find out!
In our Patient Story, we talk to Shenelle who is a very successful recovering alcoholic and drug addict. She started her weight loss journey after getting sober and is now a coach for bariatric patients struggling with food addiction. Her story of perseverance is truly inspiring.
Zoe introduces the Emotional Eating Umbrella in our Nutrition segment. This is a concept she created to help quantify and qualify all the different attributes that encompass emotional eating so that we can develop new coping strategies for each individual trigger.
Finally, we cover a few of our listener submitted questions including, thoughts on the Keto+ ACV gummies, Omeprazole after surgery, and nutrition and medication changes before pregnancy.
If you like the podcast, please forward this email on to someone that you think would also enjoy it.
We post a video version of the podcast on YouTube, but you can also find it on Apple Podcasts, Spotify, Google and a lot of other sites too!
If you have a question that you’d like for us to answer on the podcast, please reach out to us through social media (Instagram, Tik Tok, Facebook or YouTube), or the website.
In good health,
TRANSCRIPT
Dr. Weiner:
Okay, episode 21,. Vile denial and the GLP-1 shortage.
Zoe:
I feel like that sounds kind of like an episode of a cartoon.
Dr. Weiner:
Yeah, maybe I don’t know. I don’t know.
Zoe:
It has a good ring to it. I mean that in the best way possible, like it has a good catchy ring. Let us know what you guys think.
Dr. Weiner:
So, zoe, your wedding’s coming up I know Three weeks, oh my God.
Zoe:
I know I feel like we’re in this kind of strange purgatory between everything is planned, there’s not much more to do except for now. Wait until there’s lots to do, the week of like loose ends and that kind of thing, but now it’s just like.
Dr. Weiner:
My guess is you’ve had this thing tidied up in a neat little bow from the very beginning. You guys don’t know Zoe the way I know Zoe. But let me tell you something. If I ask Zoe hey Zoe, can you do this, can you help with this? It is like done Before the words are even out of my mouth. It’s been completed. She is so task-oriented and driven and she keeps her list and gets it done and right on time and doesn’t miss a beat. So my hunch is this wedding is right in your wheelhouse.
Zoe:
I do have to say so. Everything has been organized on a spreadsheet, and for my bridal shower, one of my friends got me this little desk sign that says, oh, this calls for a spreadsheet, oh, my gosh, I love it.
Dr. Weiner:
Well, I’m excited I’m going to be there and, yeah, we’re looking forward to a great night. I’m so happy for you. I just had my 20th anniversary. My wife and I had 20 years and we celebrated with a very romantic trip with our two teenage daughters. How?
Zoe:
about that.
Dr. Weiner:
I thought that was appropriate though, though, because at 20 years, it’s about your family, what you’ve done. We’re about to kind of launch our kids. Our kids are doing pretty good right now.
Zoe:
So I thought it was a celebration of that At 20 years.
Dr. Weiner:
That’s kind of what your marriage is about. It’s about your kids and what you’ve accomplished with them. So, anyway, enough about us, let’s move on into the news. Our first news article is Viking Therapeutics Weight Loss Tablet Shows Promise in Small Study. And this is from Reuters, and we’ve talked about this medication in the past. It’s VK2735. Really great, great name. That name alone tells you a lot about this medication. I’ll explain in just a second. So this is a GLP-1 NGIP gastric inhibitory peptide analog. It’s the same as terzapatide, monjaro, zepbound. Same biology, same physiology. And so the injection which we talked about showed 15% total body weight loss at 13 weeks without a plateau. That’s crazy good weight loss right.
Dr. Weiner:
Ozempic is 15%, like at a year. So this showed that much weight loss at 13 weeks without a plateau, and there were actually fewer non-responders for this injection than we see with Terzepatide. By all accounts, this looks like it’s a better drug than anything we’ve got out there. So they’re trying it in pill form and we’ve seen this with Ozempic too. Where you can get the pill form of Ozempic it’s called ribelsis and we see a lot of side effects actually with that med and not as much weight loss, and that’s what they saw here as well.
Dr. Weiner:
So they saw 3.3% weight loss. The study was only seven people and that was at 40 milligrams, which was the highest dose they used, and that was at 28 days. So 3.3% weight loss at 28 days, that’s if you’re 200 pounds, that’d be six, seven pounds, you know. Not bad, but certainly not knocking it out of the park.
Zoe:
So what about the side effects? Why is it that pill form is there are more side effects than injecting. I don’t know.
Dr. Weiner:
I’m not sure. I think that there’s something just about the bioavailability of it.
Zoe:
Honestly, I don’t know the answer to that question. It gets released in your GI.
Dr. Weiner:
Yeah, I don’t know. It’s hard to say. I’m not sure that we know the answer to that question. I don’t know the answer to that question, I’m not sure anybody does, but we definitely see less weight loss. So I think it has a lot to do with blood levels and your ability to maintain blood levels. And it may be. You know, here’s my theory. Maybe with the injections you can keep a more consistent blood level, where with the pills you know, which are dailyosed and in some twice daily dose, you’ll see more fluctuations in that GLP-1 or GIP effect and that fluctuation may cause some of the side effects. I’m not sure, that’s just a guess or a theory. So this is a phase one trial. So this isn’t even at the point where you can say, hey, this drug works. Most of what they’re trying to figure out in a phase one trial is the dose, and so they tried it at a lower dose. At 20 milligrams they saw only 1.1% weight loss. So not much weight loss at a lower dose.
Zoe:
And that may have just only been whatever lifestyle changes they were having them do too, yeah absolutely my hunches are going to continue looking at this at higher doses.
Dr. Weiner:
And so they started a low dose and they kind of you know they tried on seven people, right? This isn’t a big trial, and so the idea is you kind of ramp up the dose and, who knows, maybe the right dose is 250 milligrams, right, and they’re just given a tiny sprinkling of the medication at this level. There’s been a rumor around Viking Therapeutics and this medication, which is that Eli Lilly is either trying to buy the company or buy this medication. So I think, first of all, why do they keep naming it VK2735? Because whoever buys it is going to want to name it, whatever they’re going to name. So why invest and put some time and energy into naming it? The other thing is is that Viking Therapeutics as a company has like zero manufacturing ability, and if there’s one thing we’ve seen-.
Shenelle:
Shortages yeah.
Dr. Weiner:
Manufacturing is 90% of the battle. That’s probably.
Zoe:
They need the capacity.
Dr. Weiner:
What we’re going to see in the next five or 10 years is who’s going to become the dominant medication, the one with the best manufacturing capacity. So Viking has zero manufacturing capacity, and so for them to be able to push this out, they’re going to need to either sell it or really overhaul their company substantially. That’s not a small, small thing to do.
Zoe:
It’s probably not too quick either.
Dr. Weiner:
The interesting part is that this is a pill, and a pill is very much a game changer, I think, if not for just the increased convenience of taking a pill as far as opposed to injection, but also because pills are way easier to manufacture, way easier. You don’t need to refrigerate them, you don’t need fancy injector pens Cheaper, cheaper, cheaper to make, for sure, cheaper to make and so so the idea that there’s a pill out there that that may also address some of the shortage issues. So we’ve got Shanil coming on Coach Shanil, as she’s known on TikTok coming on, and she reached out to me and you know I kind of watched some of her TikTok videos and I’ve got to know a little bit more about her and she’s freaking awesome.
Dr. Weiner:
Yeah, I’m really excited for everybody to meet her.
Zoe:
Yeah, that’s welcome, shanil.
Dr. Weiner:
So why don’t you tell us a little bit about you? Know who you are, what your story is and what’s motivated you to put all this energy and effort into into what you’re working on now?
Shenelle:
Yeah, absolutely so. Um, it really all kind of started on December 27th of 2020. It was the day I got sober from alcohol and drugs. Um, and I’m a recovering alcoholic drug addict and I talk about it a lot on my platform. Um, and when I got sober I didn’t know that that was going to lead me to weight loss surgery or any of that.
Shenelle:
I would have by no means been a candidate prior to sobriety. The moment you told me I couldn’t drink for like even three months, I would have been like these people are crazy. So earlier than that, like a few years prior to my sobriety, I had one of those doctor’s appointments where they check your blood. He’s like your liver doesn’t look really good, so you might want to cool it on the drinking, and I passed it off and moved on with my day and my life. So when I got sober, seven months into my sobriety, I made a doctor’s appointment to have my liver looked at again because I knew it wasn’t good, and so I went in there and she did the blood work and then she was like it’s not bad. Did the blood work? And then she was like it’s not bad. Surprisingly, you’re doing pretty well, and I said the words out loud, like I’m an alcoholic. So she put it on my file, which had to happen because you know taking that kind of accountability, you know telling your doctor that it’s really hard because you know it’s on there for ever.
Shenelle:
And so when I got up to leave, I never met this woman before, like never had any interaction with her before. She was like I never met this woman before, like never had any interaction with her before. She was like have you considered anything about your weight? And I was like super offended. I was about 270 pounds at the time. I’m five five in height and I was somebody who was I had yo-yo, dieted so much. I just gave up, like this is just who I am, and kind of like on the coattails of like the body positivity movement, like I’m just fine as me. I have a boyfriend, I have a job, like my life’s fine, I have friends, you know, and she goes well, you know. I just want to tell you if you’ve been able to be sober for seven months, you might be good at this.
Shenelle:
And she handed me a referral for weight loss surgery and so I started the six month journey that my insurance required, going to the nutrition classes and you know there were nothing that I didn’t know already, like my lack of knowledge that fruits and vegetables were better choices was not something that was missing out of my brain, it just I was a convenience person and, most importantly and unbeknownst to me at the time, very addicted to food. That had been my scapegoat, probably since I was like a child, you know, and quitting drinking it sort of just merged even more. Like I don’t have drugs, I don’t have, you know. I don’t have cocaine, I don’t have, you know, alcohol, like what do I have? Food always changed the way, I feel, not as long term. It was very quick, and then guilt and shame, right, but it still gave me like that high that I was looking for. So I started the classes.
Shenelle:
I got into Alcoholics Anonymous during this time I was actually a year sober before I got into AA and I had a sponsor who I very much admired and had come from the depths of hell and back and had her life together, had a nice husband, a nice car, everything. And when I told her I was having weight loss surgery, she had told me she had done that before and she had gained all her weight back. So I was so fearful that somebody who was able to come back from her story couldn’t. I was like, oh my God, I don’t know if I can do this. She can’t do it. I don’t think I can do it. I got really scared.
Shenelle:
But one of the things she taught me when I got into the program was that I needed to start acting like a sober woman, like it’s one thing to not drink but it’s another to act like a grown up, you know. And so I applied that logic with my relationship with food. I’ve always been overweight. I didn’t know what a healthy version of Shanil looks like. I don’t know who she is, I’ve never met her. I don’t know how she acts, I don’t know how she does social settings, I don’t know how she sets boundaries, just don’t know any of it.
Shenelle:
And so I at that moment kind of dug my heels in my surgical center did not require a pre-op diet at all, just told me don’t drink and eat the day before. And I went in to get my surgery date and I left and I drove to Taco Bell and sat in the parking lot having like a moral dilemma of the insanity that I’m going to do this. And here I am and I, you know, reached out to them and asked if I could do the diet, and they said you don’t have to, and I said I’m literally in a Taco Bell parking lot right now. I need some help. You didn’t call your sponsor.
Dr. Weiner:
You called your your bariatric program.
Shenelle:
Exactly. So they were like yeah, go for it, you know, whatever you want to do. So I did it. You know I did it for two weeks. I had gone through some tough times during that two weeks. I celebrated my birthday during that pre-op diet, went through a breakup during that pre-op diet. So I really kind of set the foundations of like, if you can do it, then you can probably be okay, you know, going forward. And then I had my procedure and I hit the ground running trying to figure out who healthy Shanil was and how she acts. And then I went on TickHocked and the rest is history.
Dr. Weiner:
So wow God, there’s so much to unpack there, right, I mean, there’s so much to talk about. I think the first thing let’s talk about your history of addiction to drug and alcohol. I have said this many, many times before An ex-addict makes an excellent bariatric surgery patient because you know how to change. You’ve made actually a harder change. It’s not just, like you said, a matter of stopping drinking, stopping using drugs. It’s a matter of changing your entire life. What surgery did you have? What was your pre-op weight? Give us those stats. Yes, yes.
Shenelle:
So I was 264 pounds surgery day I was. I had the gastric sleeve. They asked me which one I want, which is always like. I’m like, do I look like I would know what I want to do around here? You pick for me please? And it was just the sleeve. Majority of us had sleeve Like. There was seven of us that day. I was the last one. I was the first one up and walking. I just I was just ready to get onto this journey and get it going. So 264, currently lingering.
Shenelle:
I hit 150 at 11 months post-op and when I saw my surgeon at seven months, he was like I want you to be ideally at 162 in 18 months. I was already at 165 at that appointment. He was like what are you doing? I was tracking my food, not eating fast food. I’ve not had fast food since my surgery and that was a huge problem for me.
Shenelle:
I don’t like to be inconvenienced, even if my health is at stake, and I had to change that mindset. So I did it pretty fast about 11 months and I’ve kept it off since. So I work out six days a week. I still track my food most days. When I eat really clean, though, which is what I do. I don’t find it to be a complete necessity to have to do it anymore. When I have clients who want to eat clean, I tell them this doesn’t have to be part of your life, but if you know otherwise, at the beginning I had to. I had to be accountable. I had to know what I what was going on. My lack of nutrition understanding was pretty, pretty prevalent at the time. How long ago was your surgery? Yeah, oh sorry, I had surgery two years ago this week.
Dr. Weiner:
Oh, congratulations.
Zoe:
Yeah, happy anniversary Thanks.
Dr. Weiner:
And so so what’s your daily strategy? Like what you know, because success after surgery, success after recovering from from food, alcohol, drug addiction is really kind of one day at a time, my hunch is there’s a lot of like regimen in your life. Is that true?
Shenelle:
Oh, there is, yeah, so talk to us about the role that that plays in your success.
Shenelle:
Right, right, you know I have to go the extra mile because I went the extra mile when I was using. You know, like I had no boundaries back then. You know, if I had to Uber 45 minutes to get drugs, I’d Uber 45, you know, if I can do that, I can put these other things together. So in the morning, like I do a lot of recovery stuff, you know, every morning I do the stuff I’ve been taught in AA, which is, you know, hit my knees and be grateful and talk about what I’m grateful for. You know I had a.
Shenelle:
Really I did struggle with the higher power thing, as most people do when they come into a program. You know, I’m running on so much self-will that the idea that you know there’s something else out there that doesn’t make all the decisions, it’s not me, it’s hard to get to and it took me a while to get there. But I do that every morning and I’m, like you know, just like, let me get another 24 hours of sobriety and another 24 hours of good food choices. That’s all I need today. And I get up, I have my breakfast, I go to the gym, I eat on a food schedule because I’m an emotional eater. So when things don’t go my way, I don’t want to eat, and then, like, once I feel better, I’ll binge. So like, oh, I deserve it. You know, this is my moment to make up for lost time.
Dr. Weiner:
Shanil, for those people out there who are saying you know what is food addiction. How is food addiction different from I like to eat or I eat too much? Talk to us a little bit about like what would really make someone a food addict.
Shenelle:
Right. You know, when I listen to my clients, like it’s always the same thing. Like, if I eat my meal right now, like I have a regular yummy, delicious, healthy meal, okay, and I’m full, and someone says, hey, do you want some more vegetables? I’m like I’m full and someone says, hey, do you want some more vegetables? I’m like I’m good. I’m good, but they’re like, oh, here’s the cake. Oh, I can make an exception for that, right. Like it’s knowing that I’m full but still eating. And it’s always the same foods. Like it’s no one’s doing this with. Like strawberries and blueberries. Like it’s always fat, salt and sugar.
Shenelle:
For me, I’m addicted to food when I get excited about it in a particular way, that I got excited for a drink and that I cannot stop, even when I’m full, I keep pushing it over and I eat a lot of it, then I feel awful about it and I regret it. I mean, it’s literally how I drink. It’ll be the same thing. I would always have the best intentions. I’m going to do things a little bit differently tonight. I’m going to go out to eat and I’m going to look at the menu beforehand and make a good choice and I get there and in the moment. I can’t. I cannot stay obliged to that. Doing the same thing over and over again and expecting it to be different to me is being an addict.
Shenelle:
When people have weight loss surgery, I think a lot of people buy into the idea that that’s going to solve the problem. And when I first read A Pound of Cure and I saw in the book or it might have been on one of your YouTube videos, but I saw you talking about leptin and I had never heard of that before. And then I read Fat Chance by Dr Robert Lustig and I was like, oh, this is something that no one’s ever explained to me before. And then it was in all these other books I read and it dawned on me that it was never really explained to me how weight loss surgery works and that it’s not so much about the restriction Right.
Shenelle:
And when I realized that, you know, after I had my surgery I had to double down on changing the food because I can eat. At two years post-op, I can eat anything you put in front of me. Nothing has made me sick, like it’ll stay down, without a doubt, you know. So there’s a difference between calories and nutrition, and so if I don’t pick nutritious foods. I’m going to end up screwed over, but I see a lot of people have the surgery and just think it’s just small portions of the same stuff from beforehand and that ends up being a lot of my clientele that come through the door.
Shenelle:
Have that thought process you know, and that ends up being a lot of my clientele that come through the door have that thought process, and I think part of it is just it wasn’t explained how it actually goes down. We had Vera Tarman. She’s an author of a book called Food Junkies. She’s an addiction specialist. She’s a medical doctor up in Canada. We had her on one of our calls the other day. She shared with us that one of the big problems with food addiction is the inability for it to be. You know, it’s not recognized by the DSM-5, so it can’t be covered by any insurances, so there’s like no support at all at all. They used to run a center up in Canada on it and it was just completely funded by sponsors, you know, and once that dried up, that was it.
Shenelle:
The food industry is a tobacco industry, right Like Philip Morris owns General Mills.
Dr. Weiner:
It is that right. No-transcript. Have very similar speech patterns, yeah, but anyway. So how does someone find out about Bariatric Rewrite?
Shenelle:
Yeah, so just BariatricRewritecom. That takes you to my stand store. I’m very, you know, on TikTok. I’m also on Facebook. Most people discover us between those two platforms. You know you can watch the videos here. We say there’s a link in there.
Shenelle:
We usually get on a call on zoom and see if we’re actually able to help you. I don’t bring on anybody that I can’t help or anyone I think that has an eating disorder. That’s out of my realm. It’s just somebody who’s a food addict and wants to have some accountability, like I’m your, I’m your person. If that’s the case, so just shooting me a message or signing up to to grab one of those calls on zoom, that’s the best way for me to see. Like I said, I’ve said and I can even assist you.
Shenelle:
So we’re very particular on who we bring on. I’ve I’ve had to say no plenty of times. There’s certain things that are just out of my wheelhouse, you know, and I don’t feel comfortable helping. But most people who come, they’re just at their wits end with where they’re at, they’re at rock bottom. And then we do get people who just want guidance right after surgery, who are like, oh my gosh, I don’t want to be that person that put it back on. I want to follow everything that you’re doing. I want to know everything you know.
Zoe:
Yeah, well, thank you so much for being here. It was really really inspiring and wonderful to have you share your story, and thank you so much for being vulnerable.
Dr. Weiner:
Yeah, and honestly congratulations on all that you’ve accomplished.
Zoe:
Yeah, it’s so impressive.
Dr. Weiner:
You know, I mean, you were at the very bottom and you really have put in so much energy and so much hard work, and now you’re using that to help other people. So I love that you’ve kind of been there and and you’ve channeled this not just to save yourself but to help save other people too. So so you know, fantastic work and, and you know, anybody who is in your orbit is, I think, lucky to know you, I’ll tell you, so impressive.
Dr. Weiner:
I’d say so impressive and you know, I think I mentioned this earlier in the interview but I found that ex-addicts make amazing weight loss surgery patients. Amazing weight loss surgery patients I think Shanil is, you know, exhibit.
Sierra:
A right, there she’s absolutely crushing it.
Dr. Weiner:
So let’s move on to our nutrition segment. What do you have for us this week, Zoe?
Zoe:
I have something that I’ve made up, known as the emotional eating umbrella.
Dr. Weiner:
Oh God, I got to hear more about this, yeah.
Zoe:
Yeah, so this actually came about because of our emotional eating support group. I found myself describing this concept over and over again and that’s how it’s now been named, so the emotional eating umbrella those of you who are listening and not watching on YouTube, I talk with my hands a lot and I’m making the umbrella. So we often think about emotional eating. What is that? That’s the response to food, to use food for comfort. But emotional eating encompasses many different emotions and if we try to just clump in our response or our alternative activity or our new coping strategy, the same for all of them oh, you know, just go for a walk. Or oh, read a book, you know, whatever it is, distract yourself, right.
Zoe:
If you have not first identified the root emotion that is driving that desire to emotionally eat, it’s not going to be very helpful or productive. So under our emotional eating umbrella, we have boredom, we have stress, we have loneliness and sadness, frustration, celebration, right? There are so many different emotions that fall underneath this umbrella and we need to identify how can we more productively cope with each individual emotion, because what you do to cope with boredom and what helps satisfy that boredom is not what we want to do if you’re experiencing loneliness. In fact, it might make that loneliness and that desire to emotionally eat worse. So we definitely dig deeper into that in the emotional eating support group. But I just that’s kind of my. My segment today is about first needing to ask yourself what is the emotion that I’m feeling. Create that pause, identify the emotion, so then you can more productively cope instead of reactively using food.
Dr. Weiner:
I mean that’s fascinating, that’s so important because, you’re right, we kind of lump it all together, but it’s not, it’s very different. And actually I went and visited some friends a couple of weeks ago and my friend was really into meditation, meditated every day, and so I was like you know, he’s like, do you want to do it? I’m like, let’s give it a shot. How do I? You know, I haven’t really done that. It’s something I’ve talked about, I’ve read about it. I’m very meditation curious.
Zoe:
You’re like. You know that you know the benefits, but the of clear your head and clear your thinking.
Dr. Weiner:
And just said meditation is at its core, kind of sit quietly for a specific amount of time, so, but the thoughts are going to pop in your head. He said what you have to do is just identify that thought, say, oh, there’s that thought, instead of reacting to it. Our normal response is, when we get a thought, when we get an emotion, is I’m going to react, I’m going to respond. This thought is going to somehow control me.
Dr. Weiner:
And meditation, he explained to me, is very much about hey, that thought is just a thought and it’s not reality. It’s just something that is in your head at this very moment. And he said you kind of just push it aside and I think this is kind of an extension of that is like hey, actually I’m feeling lonely, let me identify this, let me acknowledge it, that’s okay, there’s nothing wrong with feeling lonely. Everybody feels lonely, everybody feels bored. And then, once you identify it, now you have your strategy. So to some degree it’s kind of that awareness, that mindfulness, that understanding that just because a thought pops into your head doesn’t mean that it has to control you. I love that Great, great idea and I think you got to build out that umbrella almost for everybody.
Zoe:
Exactly, and that’s what we do in the session. We kind of identify those root emotions, identify. Okay, if you’re feeling lonely, maybe instead of doing a puzzle by yourself, you FaceTime with your best friend.
Dr. Weiner:
Okay. So our economics of obesity segment today is about single dose vials and I actually have to give some credit to On the Pen, the man on Monjaro. He’s on TikTok and Instagram and I think he has a podcast. Actually, this guy’s really smart. He’s so on top of like every study and every trial. He’s really putting some very good content out there. So feel free to look him up.
Dr. Weiner:
But he pointed this out on a video that I saw and I looked into it and he’s 100% right that when you apply for FDA approval for a medication, it’s not just about the medication itself, it’s also about the delivery method. And that’s particularly important for injectable medications, because if this medication is going to backfire, is going to overdose, if it’s going to allow for infection or contamination of the medication, that’s a big problem. So the injector pen is a big part of the FDA approval process and so when Monjaro and Zepfam, when these meds get approved, they’re not just approving the medication, they’re also approving the injector pen. Anybody who’s used these medications knows these injector pens are super complicated and there’s a lot of rumor that much of the shortage that we’re seeing is being driven by the injector pen, not just making the medication, and we also see again mentioned this before same price for different doses, which kind of makes you think like maybe the cost is in the pen.
Dr. Weiner:
Right exactly Right. So it turns out that Monjaro has, and is, fda approved for dispensing the medication in a single dose file. This is what we see in Canada. So Canada is much more proactive than the US about a lot of these things, and so when they wanted to get Monjaro out there, there was a shortage of the pens, and so they went to Eli Lilly and said, hey, release it as a vial, no biggie, we’re good with it, we’ll pass it through.
Dr. Weiner:
That’s simple, and the idea is you take an insulin pen, just like diabetics have been doing for decades, and you pull it out of the single dose vial and you inject it right in yourself. You know, really not that complicated. So it turns out there’s something called an NDC number. An NDC number is something you need in order to write a prescription. These are not available. So if you write a prescription, nobody’s going to be able to get a single dose vial. You can’t go down to CVS and get the vial. It’s not like, oh, we’re out of the pens, but we’ve got the vials. They’re not manufacturing it.
Dr. Weiner:
And so my question is why not? It’s cheaper, safer. They’re still going to use it. People are still going to buy it. It’s not going to change a thing. So I don’t know the answer to this. I don’t know why Eli Lilly’s not. Usually these have to do with money. I think the big problem is is that everybody’s going to want the high dose bile and just say like, oh, I’ll just sneak out a little bit. And we’ve saw that a lot with our patients who were getting the medication from Canada. So my hunch is it may have to do with their ability to sell, but right now they can’t keep up with demand.
Dr. Weiner:
So even if people are, diluting it, not, you know, using it. Don’t think there’d be an issue selling it because everybody’s trying to get it. But if the injector pen is really the issue, they could just only produce 15 milligrams of the single dose vial and you know that would get sold and there’s some issues with that. You got to do that with supervision and some guidance, but this would really increase access. And my concern is that Eli Lilly and Novo Nordisk are really just jockeying for position to be the dominant medication to keep their stock price high and really just focusing on the big long play with these meds as opposed to making sure that their current needs are met.
Dr. Weiner:
And again, my theory on this is that the company that fixes the manufacturing problem is going to be the one that becomes a dominant medication, and so I think this is a real opportunity and I’d love to see Eli Lilly and Novo Nordisk taking this and running with it and doing whatever they could to get more of this medication in people’s hands, because for some people it’s such a game-changing medication. So I thought that was an interesting thing. Again, on the Pen, or man On Monjaro, check out his stuff. He really puts some really good content out there. All right Sierra, why don’t we move into our questions from social media?
Sierra:
Okay, perfect. So first question is from the website from Camilia Is the keto apple cider vinegar good for someone? I see that it takes off a lot of weight, but I wanted to ask if it was safe.
Zoe:
Okay, so this is a for those who maybe aren’t familiar. This is a supplement that’s in the gummy form, so it’s like a gummy keto apple cider vinegar, those are, you know kind of what it says it’s on there. Um, what’s interesting is that it’s marketed as a keto product, but there are four grams of added sugar per serving, so if you’re familiar with me.
Zoe:
Well, yeah, exactly, you’re trying to. If I’m having four grams of sugar, it’s not going to be from a little gummy. It tastes like apple cider vinegar. It’s likely I don’t know who said that it took off a lot of weight or who saw weight loss or what else they were doing in conjunction. Maybe they were also on ZepBound and taking these apple cider vinegar keto fake keto gummies and seeing weight loss, but that’s not going to do anything. Apple cider vinegar, when you get it with the mother, is a probiotic food because it has those healthy, active life cultures, which is great. That’s a good bacteria to help with your gut microbiome. When you’re buying it in the gummy form, you’re not getting anything. You’re getting sugar and you’re getting gelatin. So also, we’ve talked before about making sure that the supplements that you do choose are third-party tested, are safe, are effective. If you’re going to be using your money on a supplement, I would want you to be using it on a high-quality multivitamin instead.
Dr. Weiner:
Yeah. So when you get apple cider vinegar, like, let’s say, at the grocery store, is that probiotic or is that going to be sterile?
Zoe:
If it has the mother at the bottom, like you know, it looks like kind of like cobwebby, gunky stuff at the bottom. Yeah, that means it’s going to have those.
Dr. Weiner:
That’s like what you see at the bottom of kombucha Right yeah.
Zoe:
Okay, but there is the like you know, kind of cheaper version that it’s all clear that’s not going to give you the same effect. Drinking apple cider vinegar is not going to. Maybe it’ll make your stomach a little queasy, and I know dentists don’t want you to do that. So yeah, I would just be careful.
Dr. Weiner:
What’s our next question, Sierra?
Sierra:
Okay, this one is from Kate. What is the timeframe for taking omeprazole after sleeve surgery? Should we try to wean off of it over time?
Dr. Weiner:
So I think, first of all, it’s important there’s a difference. This answer is different whether it’s a sleeve or gastric bypass. So, omeprazole or pantoprazole, it’s a proton pump inhibitor and it’s a medication we put all of our patients on. Now I put everybody on this and surgeons are going to have some different answers to this, but I can tell you what my practice is. I put everybody who has a sleeve gastrectomy on pantoprazole Again, same drug.
Dr. Weiner:
There’s no real difference between these medications. I put them on it for one month and I do that to reduce the acid in the stomach because, especially after surgery, as the stomach is kind of waking up, there can be some acid reflux. The acid reflux can cause some esophageal spasm and make Zoe’s job of getting people back on their fluid, back on their proteins and back on solid food that much harder. So we put everybody on omeprazole for one month and after that we tell them stop it. And because the goal is to not be on omeprazole long-term, there’s a lot of talk about osteoporosis and dementia risk from prolonged use of these medications and I think at this point we’re starting to see enough evidence that there might be something to this, that this may not be a medication you want to. It’s just totally harmless to take for the rest of your life, so we try to get everybody off it. Now the big issue is that you know sleep patients get reflux, and so a lot of sleep patients will find themselves back on omeprazole.
Dr. Weiner:
If the omeprazole works, we kind of ride, you know we go with it. We sometimes try Pepsid, which is famotidine, which is not a PPI and may not have those same effects, but it has its own issues as well, and so this is something you’ll have to work with your surgeon on if you do have acid reflux. But the goal is really to be off omeprazole or pantoprazole any of these medications after the first month With a gastric bypass. What we typically do is we put people on it for six months to reduce the risk of a postoperative ulcer. You people on it for six months to reduce the risk of a post-operative ulcer, you’re at a little bit of an increased risk for an ulcer in those first six months and that can make eating and drinking harder, and so we treat our gastric bypass patients for six months, but then we stop and very, very few of them need to restart. We do occasionally see acid reflux after a gastric bypass, but it’s pretty uncommon, truthfully.
Zoe:
And they can just stop it, or do they need to wean it off?
Dr. Weiner:
Just stop it. The other thing that I have people do is just take it as needed. So when you get acid reflux, take some omeprazole. And then, of course, dietary adjustments right, and that’s where the avoiding mint and coffee and tea, things that relax the lower esophageal sphincter you should avoid those, all right.
Sierra:
Our last question, sierra, those All right, our last question, sierra. Okay, this one is also from our website. What changes should I make with my nutrition and the medications if I would like to become pregnant?
Dr. Weiner:
So why don’t you talk a little bit about nutrition first, and then I’ll cover the medication?
Zoe:
So my number one thing here would be protein. It’s not that you’re eating. We don’t want to have the mentality of eating for two. The amount of extra calories that one needs at each trimester is not nearly as much as Americans do. So really just making sure that you’re reaching your protein goal, maybe bumping up protein a little bit higher, but then also thinking about those key micronutrients, the iron, the folic acid. That’s what you get in the prenatal vitamins. So if you have had weight loss surgery and you’re pregnant, we just recommend that you take two prenatal vitamins. Make sure it has iron in it.
Dr. Weiner:
Yeah, I think that’s. One of the key things to really talk about is the importance of eating healthy while you’re pregnant, and this is something again in the past we’ve said eating for two and it was like a free pass to eat whatever you wanted. It’s probably the worst advice you can give somebody, especially someone who’s struggled with obesity.
Zoe:
Well, and because it also can, it has that epigenetic effect.
Dr. Weiner:
Absolutely.
Zoe:
Pass it along to the next generation.
Dr. Weiner:
Yeah, exactly what you eat in utero is going to affect your unborn child’s metabolism in the future. It can either turn on or turn off the genes that cause obesity. So eating really, really healthy is critically important. I think the other piece and this is something we’re going to, I’m sure, touch on in future episodes I actually I just saw that we had another question posted about pregnancy and the GLP-1 medications is the GLP-1 medications are not approved for pregnancy.
Dr. Weiner:
If I have a patient who is on GLP-1 medications and they become pregnant, then I will not prescribe them anymore, and nor should any physician. They’re not approved. Now there’s different classes of drugs. I believe they’re class C, not class D. Class D is we know they cause birth defects. I believe they’re class C, which is we don’t know and so we don’t recommend With pregnancy.
Dr. Weiner:
If you don’t know, then you don’t take it. It’s only when there’s data that supports the safety in pregnancy. So this really creates a really challenging problem Because, let’s say, you’ve lost 50 pounds on Zepbound or Ozempic and again the manufacturers recommend that you stop taking the medication two months before trying to become pregnant. The problem is that then you start gaining weight and so now you’ve got pregnancy, which is a weight gaining event, and you’ve got stopping the meds and you can gain 50 pounds in that first trimester. We don’t know this. We don’t know what the right answer is.
Dr. Weiner:
My suspicion is the right answer is going to be to use the meds and that they’re going to be proven safe. But I don’t know that and I would not prescribe them. I think that only because I believe that there’s going to be some harm here. I believe that there’s some potential danger, and I think if you’re childbearing age and you have plans for pregnancy in the future, you should be really careful with the decision to start a GLP-1 medication, because you could all of a sudden find yourself in this position where you’re going to get pregnant and then rapidly gain a bunch of weight in your first trimester, and that’s not a good. That’s not good for you, that’s not good for the baby, and so this is something we don’t know the answer to and it’s something I think we have to be careful about. I bet you’re going to hear more and more about this in the coming years, as we have more and more people on this medication.
Zoe:
Right, it’s all about getting more data.
Dr. Weiner:
Yeah, so anyway, my hope is that we’ll show that they’re safe for pregnancy and that would kind of solve this problem, but until we know that, I think there’s some risk. All right, another great episode, great patient story. I loved having Shanil on. She was really awesome, I mean, what an inspiration, and I’m so lucky to kind of have gotten to know her a little bit. If you want to meet up with Shanil, reach out to Bariatric Rewrite and if you’re interested in hearing more from us, check out our social media channels on Instagram, tiktok, youtube, and if this podcast is helpful, please share it with someone else that you think may find it helpful.
