For this DrTalks. I have an amazing guest and I know everyone is going to learn so much. This is Dr. Sowa and she is an internal medicine physician as well as an obesity physician.

She's the founder of SoWell Health. She has a virtual medical practice and a whole host of metabolic health products that are direct to consumer. Thank you so much for joining me, Dr. Sowa.

Thank you for having me. I'm so excited. So we are talking about the new class of medications, these GLP-1 receptor agonist medications like Ozempic. And we're going to go into you know, the details particularly the side effects of these medications, how they work and what people can do to minimize those side effects.

I'm sure I know you see this, but I have people who come to see me to start these medications, and they're so nervous about the side effects. And I spend so much time, you know, having this conversation with my patients.

So I can't wait to learn from your expertise on how you have these conversations with patients. And so we can bring down the fear about these revolutionary medications.

Yeah. You know, you know, when we were thinking about what's talk about, today, there's so much to talk about in this field, but these medications are so life changing and so revolutionary, but they don't work if you can't stand them.

And it's not worth it for people to see them if they don't feel well. So I'm super passionate about talking about how to mitigate side effects and how to know what the difference between an explosive headline is.

That's not really a side effect versus what we really need to look out for. And there's the most, common thing that people experience. It's just in the middle. It's they're not really side effects.

They're kind of the way that the medications work. And you just need to mitigate and minimize how these medications can make you feel. So I'm excited to get into it.

Well, let's start with the basics of how these medications actually work. So why do they work? Why are they effective for weight loss? What is the mechanism by which they do their job.

Yes okay. So let's talk about the two categories. So we have GLP-1 agonist medications. And then we have the slightly newer class of GLP-1 plus g p hormones.

And so the Ozempic s fall into a class of just GLP-1. And so ozempic is technically approved for type two diabetes. And the brand name is Wegovy for weight loss.

And then on the flip side we have Mounjaro for type 2 diabetes and the two hormone class medication and then Zepbound for weight loss. We kind of as a society have collectively called them Ozempic, but it's a bit more nuanced than that.

And I think it's really important to recognize that they have different indications and different names, but they really fall into very similar kind of buckets.

And the way that these medications work fundamentally, I like to tell people in three big ways. They work on the brain, which is the way that makes them the most effective.

And then they work on the stomach and the gut, and then they work on the level of the pancreas and really, we've thought for a long time that weight loss was about calories in, calories out, willpower.

And we just really know that that's not true weight regulation, really, when it comes down to it comes down to the central nervous system and your brain.

And that's what makes these medications so much more effective than anything we've ever seen. You know, if you go on TikTok or Reddit, you'll hear people talk about food noise being quieted.

And that's not just appetite suppression. That is this drug working very, very powerfully on the, on the level of the brain and our nervous system. And then we have these secondary effects on gastric emptying.

So food sits in your stomach longer, making you feel fuller. But that fullness isn't just in the stomach. It's hormones going back to your brain and that brain talking to your gut.

And so that's really how that's working. And then on the level of the pancreas, why this drug is so effective for blood sugar management is that it really makes your insulin more effective.

It really kind of bypasses insulin resistance, which is so prevalent among people trying to lose weight. And it it makes us reduces inflammation, lowers our blood sugar.

And that process allows us to tap into our fat stores for energy rather than just storing everything we eat over as fat. Because you and I both know that most of our patients come to us saying, I've tried everything and I'm doing so well, and I'm eating healthily, and I promise, I promise, I promise.

And I'm like, I trust, I trust that you're doing all the right things. I know that this is super complicated. So these medications give really an age to behavior change and and work on a deep level.

So I'm all about them because I'm all about helping my patients lose weight and gain health. I think you know what you said about the patient who comes in and they describe to you, I have tried everything else, and I'm sure you're like me.

You want to know what those things are? We ask just because it gives us some understanding. But I absolutely believe my patients when they say they've tried everything and it haven't worked because obesity is a disease.

There's a lot of physiology going on that even when you're doing all the right things, it does not guarantee weight loss. And so I think it's a really powerful message for people to hear that if you feel like you really have tried everything, you have tried different nutrition strategies, you've tried changing your movement, you've logged your food, you've worked on your relationship with food, and you're like, I still am not losing weight, or I still have so much food noise, or it's just not working for whatever reason.

Then medications often really are the solution. Yes. Yeah. And you still have to do those things and you don't have to do those things first. In my book to qualify for these medications, we don't have, we don't have red tape around these medications.

Right. It comes down to BMI and comorbidities meeting other health issues that you have. But it's crucial that once you start the medications, and my advice is a little bit before is to adopt all the things that you just mentioned.

Right. Because they go hand in hand. These aren't magic wands. And that your patient health needs isn't that you see the same thing all of a sudden. They can do those things, right? Yes.

My patients come back and they're like, now I can just have a salad for lunch and I'm full and I'm satisfied. Right now I can have one piece of pizza.

Like right now I've lost 50 pounds and I enjoy running right. Like it lets them all work together, right? Right. I mean, it's really life changing because for a lifetime people have tried to diet and lose the same 20 pounds, and those 20 pounds turn to 30, 40, 50, 100 pounds over time. And they want to be the person who now makes healthy decisions, but also can enjoy a family meal that is not 100% restrictive or diet all the time, right?

It really these medications, they release people from a lifetime of dieting. Wow, what a beautiful way to put it. Yeah, I mean really, it gives me the chills.

I feel very lucky to be in this field right now because, you know, you and I have both. We're not new at this, right? We've been doing this for a long time, and we have other tools at our disposal on other medications, but they're not nearly as effective and they're not nearly as life changing.

And I'm a big believer in and to take a step back, I'm a big believer in a holistic approach to weight loss. So none of my patients are just getting a script for a medication.

And it is all about what they're eating, how they're eating, how they're exercising, how they're thinking. You know, cognitive behavioral therapy is a big foundation of my practice.

And you have to keep working on all of these things. But these medications, like you said, just allow them to do that. But I have a lot of patients who come in with a lot of fear, or they don't even want to consider the medication because of what they've heard in the media about side effects.

So give us the real deal on the side effects for these medications. So people experience what might be clumped into side effects in on these medications.

But really we have to think of them as a they're side effects of how the medications work, not just random occurrences that are negative. Okay. So because we have delayed gastric emptying and we have a decreased thirst mechanism on these medications, decreased hunger mechanism, decreased thirst, the biggest thing that we find are nausea.

Nausea is number one. And then constipation and diarrhea are the next side effects that happen. People will also report fatigue or headaches. Those I kind of loop into dehydration.

Up to 50% of people experience these in a in a significant way throughout their journey, and they will experience them traditionally, when you start a new dose and every time you go up, you titrate up on these medications.

And these medications take anywhere between four to really a year to titrate up to the full dose of medication. But if you just followed a titration protocol, you have 4 to 6 months.

But not everyone needs to go up every month. And so that's quite a long time to be feeling not optimal. Right. And so not constant nausea will make someone stop diarrhea constipation stomach upset.

And I mean these are enough to that that actually while in the clinical trials it's pretty small that people start maybe 5 to 12%, 15%. When you look at the prescription patterns, the what's what we're kind of finding in real world that 50% of those 50%.

So about 25% of all users will stop this by year due to side effects. And so that's a lot. And in my book, that's why I have gone hard on educating against that how to manage side effects.

And my company is has released by the time that this podcast will come out, we've released a three step supplement protocol system to help people at the side effects.

Because if you can't stay on the medications, you're not going to reap these amazing benefits that are giving us the chills. You know you're not going to be getting to your 20 plus percent total body weight loss.

You're not going to be getting to reversing sleep apnea and preventing heart disease. And, you know, improving joint health and reducing blood. You're not going to get to it if you have to stop.

So let's talk about how to stop it. I love it. And, you know, it seems like over the last year there's just been a push everywhere to get the medications right.

Like there's all these companies that have popped up to help people get the medications, but there's so few people doing what you're doing, which is how do we support people on the medication to, minimize side effects, help the medication work the best and be the most successful.

So thank you for what you're doing because it's really, really needed because these medications do work really well. And I love your framework that some of these aren't really even side effects.

They're just a little bit of consequences of how the medication works on the gut. And so if we know that we can anticipate it and we can supplement it and eat in such a way to minimize those side effects.

Exactly. So when it comes to the first one, which is nausea, I often find this has to do about timing and quantity of food, but also hydration. And so I mentioned it earlier. But your hunger is suppressed but also your thirst mechanism is suppressed.

So one of the foundations of my program is drinking enough and not just drinking water, which is a little confusing because water is the healthiest, right?

I want you to drink water, but I find that electrolytes in the form of salts, magnesium, and potassium are very, very helpful, at staving off dehydration and then also helping with that nausea that can come with dehydration.

So I have many of my patients who wake up in the morning and say, I just don't have an appetite. I will have them start their day with an electrolyte drink.

And I just find that this gives them a boost. So back when we were in medical school, we learned that you can't just have water and a little piece of bread, right?

You called tea and toast syndrome, and you would see it in little old ladies who had become so salt depleted and in effect, dehydrated, and water wouldn't go into the right parts of their body.

And the same thing on a very minor scale can happen when you're on these medications, because you might not be eating enough and you're not drinking enough.

So if we are getting the right amount of water in which is at least 64oz of water a day at least, I also find that people do better when we add some salt to that, and a pinch of salt can do, but it also magnesium and potassium can be very helpful in the rapid weight loss process.

But I would advise people to look for sugar free iterations. It's really important. Some of them are loaded with carbohydrates. That's not what people need on their weight loss journey.

That might be needed for a marathon or an extensive runner, but we need a little bit of a different profile. So hydration is is crucial. And then not eating too much.

So this can be a triggering thing for people to hear who have been on a weight loss journey their whole lives. And really don't overeat. And, you know, like they're like, I'll watch my portions.

Well, your body responds a little bit different to these medications and a big leafy green salad that might feel super healthy and eat healthy. I'm not saying it's not might not make you feel so great at the beginning.

And so I have people really prioritize their proteins first. So in the traditional weight loss world and eventually how I want people thinking about food, we think about volume metrics.

So fill yourselves up with the healthy leafy greens and the voluminous foods. But at the beginning when you start these medications, your stomach doesn't have the capacity for that.

And I've actually had some people, people get really sick in my practice, like eating a very delicious kale salad. There is nothing wrong with kale, but too much of a good thing at the beginning.

Can can be hard to digest because that food sits there and you just don't feel so well. So I have people really prioritize protein, and if you're not hungry, which often happens at the beginning, and it's such a wild concept, if you're listening to this, you're like, that's not going to be me.

But often it is. And at some point along the journey of titration, your hunger can be so ratcheted down that you don't feel like eating. And so we go back to that original concept of can't just get water without the sore you.

Right? You need the electrolytes, but you also need some food. So if you really aren't, can't still or like I can't eat a piece of chicken, I don't want cottage cheese.

Protein shakes can be very helpful. So you get the protein and still provide you with some nutrition. I am not a chic based doctor. I've never carried, you know, shake systems.

I think, you know, the very low calorie diet. But occasionally the premade protein shakes or powdered protein can be very, very helpful. And they also help fight against what I think a lot of these headlines have said about a long term like the Olympic phase is epic, but, you know, like all these crazy headlines that really are just about rapid weight loss and, you know, your skin holding up and your muscles.

Right. We'll we'll talk a little bit more about that. But we need to make sure that we help people not just lose that, I'm sorry, not just lose weight, but that the ratio of fat loss is more than the ratio of muscle loss.

You can't just lose fat. Unfortunately, that's that's not how it goes, right? As your body shrinks, you lose both muscle and fat. So we want to make sure that we preserve muscle mass and protein and the way that we eat it and prioritize it is super important and helps to minimize side effects.

The other thing to say about food is that if you eat processed food, I see all these TikToks people like, I had to like French fries today. Let's not going to get you very far in the journey right?

Carbohydrates and specifically processed ones can also make people feel nauseous on these medications and really kind of turn their stomach. So, I have people really think about protein for many reasons in the way that it makes them feel.

Well, it keeps their muscle mass up. If the right density of food and you don't get these nausea and then diarrhea side effects too, that come from simple processed carbohydrates.

People can't see me while you're talking, so only one of us are on time. But I'm over here with this big grin on my face. I'm like, yeah, yeah, yes, because these are all the talking points that I 100% agree with.

Because, you know, when someone starts these medications, they usually have done lots of different diets and they've worked on their food, their eating and their behaviors for a really long time, and all of a sudden they feel full easily.

They're not hungry. And the strategy has to change, right? Eating a big leafy salad to feel full doesn't complement this medication. Now you're going to feel full, which might even mean you feel kind of sick, right?

Because you had too much in your stomach for this medicine, and then you didn't get the protein that you needed. And then the other thing is the not eating, right.

People are like, oh, great, I'm not hungry now. I don't have to eat and I'll just lose weight. Well, we want you to get a little bit of stuff in your body, particularly, like you said, those electrolytes and some protein.

Otherwise you're not going to feel good and you could be at risk for losing the wrong type of weight, right? Where now you're losing your lean mass, your muscle, which we don't want you to lose or lose very much.

So what a wealth of information. Yeah. You know, I think you and I, as we've been doing this for a while, right? You know, not to show our age, but we're not, like, we just started this last year, and.

And I think as we've gone on and become very comfortable with these medications, you really. This is not the stuff that comes in the package insert, right?

This is stuff you learn clinically and working with hundreds, thousands of patients over time. And so I've really refined exactly how I tell people to eat and the kind of the protocol so that they can go on and stay on these medications for a long time and reap all the benefits.

There was one more that we didn't talk about. Do you want to get to constipation? Absolutely, yes. Let's talk about constipation every day. Poop. Yeah, exactly.

So this is the stuff that makes people feel pretty miserable. I find that constant nausea makes people feel unwell. And then on the actually upper GI side effects and then constipation, right.

Like there's nothing worse. And your whole GI system slows, so it starts at the stomach and then it goes all the way through the small, small and large intestines and the motility, the movement of your gut is down.

So we already talked about importance of hydration. It's really, really important. The fiber is key. And you might have just been paying attention and heard, well, we just told you to not eat the bulk bulky salads.

And the way that, you know, is the optimal way to get in fiber. Sometimes it's really hard to quite honestly get to fiber recommendations, through through leafy green vegetables and beans and legumes and things.

But you can, but you probably can't at the start of your journey on these medications because you just can't get it in. And so a fiber supplement is very, very important for both preventing constipation but also diarrhea.

So I am a fan of psyllium husk because it really is the thing that helps on both ends of the spectrum. It really adds bulk to stool to help things moving.

And then in the flip, if you are experiencing diarrhea to kind of bulk things up. And I never thought I would talk about poop so much in my career. But it is important that these medications and preparing yourself from the get go, and, you know, really making sure that you're kind of got your buy list is what I call it at the start.

And that's where my my company has developed a three step protocol that involves everything, make it easy and kind of put everything into one just to help people from they go pick up your prescription, and every month you go pick up these three things that will help you kind of keep going, really, just to get your money's worth out of these medications and to feel well, because, again, we're not trying to make anyone feel sick.

And if someone says, I feel so sick, I did. Something was not right about the way that they went about that. Yeah. And, you know, one thing a few of my patients have said is they feel like if it isn't hard or they're not suffering, it's almost like it's it's not it's too easy, like they're cheating or something.

And I'm like, whoa, like, let's let go of that. Right? Like you shouldn't feel tortured or starving when you're trying to lose weight and you shouldn't feel uncomfortable like you shouldn't have to have terrible side effects, you know, to lose weight.

So like, no, you don't have those things. So let's help you help yourself to not feel that way. Right. So can you tell us more about I mean, we hinted out them, if people have been paying careful attention, they probably know what the three things are.

But can you tell us about what those three steps are? So daily electrolytes and hydration. Right. At least 64oz. And the electrolytes were really help.

We need to be hitting high protein goals throughout this journey. So I simplify it by saying at least 20 to about 40g of protein per meal. We can get a little bit more scientific about it, but that that really is what it breaks down to for most people.

And you need to prioritize your protein at these settings. And on the days you really don't feel like eating, we're going to make sure that we get it in through a protein shake or an easy sauce, a condensed form of protein.

And I really want my patients eating whole food, and I want them cooking and eating and enjoying. But but life is complicated. And I like a protein shake in the morning. So I start my day.

And also at the beginning, you just don't feel like doing a lot of those things sometimes with these medications. And then the third step is protecting your gut and preparing your gut.

So we're not only going to be drinking water, but we're going to be taking in a fiber blend, potentially a probiotic and digestive enzymes to help along with the breakdown of food and to keep things moving.

And this really, really sets, sets people up for success. One of the things you said, which almost all the experts I've interviewed have talked about, is the importance of eating real food, right?

That we should eat whole food whenever possible. But I think it's really important to note that when we're talking about, you know, adding a protein supplement or adding an electrolyte supplement, those are supplements.

They are like the icing on the cake. They're layered on top. And so they're very intentional, sometimes even processed foods, right. When we think about a protein shake.

But it's being really in an intense way to supplement us eating this mostly like real food, less processed diet. Oh, of course. And it's, it's really like I, it's for our company.

We created everything in stick packs on the go because this is intended to just augment people's lives because it's it's ideal. Like in my ideal mind, I'm like homesteading and I have chickens and, you know, I'm making all of my food from Sky.

You say the exact same thing. I'm like, in my ideal world, I have my own ranch where everything is right, you know? Totally. And I have a lot of kids.

And so I'd send them out and they'd be doing all these chores. I mean, this is where my. But it's not our reality and it's not the reality for most people.

And so it's picking the healthiest choices and the healthiest foundations. And again, at the beginning, sometimes it's okay. It's okay to have your kind of go to supplements and things that maybe like this is maybe not.

This is I was never just eating cottage cheese for lunch before. This feels like. But it's straightforward and you're getting like the bare minimum of what you need.

Not the cottage cheese as in a whole food, but just kind of like pairing it back. Simplifying. And sometimes products can help us do that. I love it. I think that's such a great mindset.

And like a reality check rate of like, this is how I would love to live again on my ranch where I control all the food and I know it's farm to table and amazing, but that's not the reality of the world that I live in.

And so I'm making the best choices I can to nourish my body. And that's what I encourage my patients to like. Well, what makes the most sense? Because if you don't have the easy thing in the quick pack ready to go in the little, you know that you can add, what are you going to do instead?

Are you going to stop and grab fast food? Are you going to run into a convenience store and get a bag of chips? Like, let's do the best option we have to support our health.

Right? Right. I it's funny you bring up chips because people will crave chips, right? They need that salt. And so again it's like you need to feel wall right salt water.

And you're like but maybe the chips that's like more processed right. Like let's pick less like less processed options. Same thing with proteins. Like could be starving for something or you want something sweet like we can a protein shake can take that that place, where something that's a little bit more prepared.

And so I 100% like the fact is we live in this world. Ideally all food, like nothing comes processed. We change the entire way that we source foods in this country.

I'm a really big I'm I'm a big believer in that. I feel like our foods are just filled with a lot of junk in the way that I created my products for our company, we minimized.

It's just so straightforward. What we have, it's minimized. We don't have any additional sugars or additives or things that are necessary because pure is best.

And when it comes to food, that's the truth too. But, you know, we have to exist to be real. We're kind of in this predicament because we just do live in the world that has cars for convenience and air conditioning.

So we're not sweating too much in heat, so we're not shivering, right? Like our bodies, we our bodies exist in this world now. And so we're just kind of coming to meet those needs.

So in your experience, you've been, you know, treating obesity for a long time. You've been using the medication since the beginning. When you mitigate these side effects, when you use strategies like you've discussed, what percentage of your patients are able to successfully stay on the medication and not have sort of intolerable side effects.

On my my practice, it's approaching 99%. I mean, in a very, very rare few. I mean, I can't even think of anybody in the last four years who has stopped due to, due to side effects.

And it's education, education expectations setting, that is really the foundation for people understanding. And how do you help? How can you come around feeling better and knowing that some days you might feel the side effects more than others and but that eventually we will move beyond it?

And so with that, my patients do do very well, much better than the average population. I think. I mean, and I believe it because I know that when people have that support and they have the right tools and they know what to do with the medication, their success rate just skyrockets.

Yeah, yeah. And I mean, I don't know if people have been listening up until this point. Can we share with them what I've been working on to please. So if you're listening to this when it comes out, I am excited to announce that I'll be writing.

I have written a book, author of a forthcoming book with HarperCollins called The Ozempic Revolution, and it is a practical guide to navigating how to approach these medications, how to minimize side effects, what to eat, how to think.

It is my program in a book form, and I want to make I there's only one of me. And so I, I'm trying to bring more education to just the millions of people that will be on these medications.

Oh, I have goosebumps because it is so needed. So thank you so much for making that book, because people, you know, need more support than they can get in just a few minutes with whoever's prescribing the medication.

And there is so much they can do to be more successful on the medication and really use it as a powerful tool. It is. Yes, yes, I'm so excited. So if people want to stay in the loop, find more from you.

Find your products. Where should they go. Over to getsowell.com, And I'm on all socials @AlexandraSowaMD I love it. Well thank you so much for joining us and for all you're doing to help people be successful. Thank you.

Alexandra Sowa, MD

Managing Side Effects In The Era Of Ozempic