GLP-1 Medications for Weight Loss: What You Need to Know | Holly Lofton, MD

Introduction and Guest Welcome 0:00

Welcome to the coalition. This is a talk show dedicated to discussing health, wellness and inspiration. I'm your host, Doctor Shani Belgrave. Hello, everyone. Thank you so much for joining the coalition. I'm your host, Doctor Shani Belgrade. I am a bariatric and minimally invasive surgeon in Atlanta, Georgia. I'm also the founder and CEO of Aneka Bariatric and Wellness. You can learn more about me and get connected at Doctor Shani belgrave.com. I am excited to welcome to the show doctor Holly Lofton.

Doctor Holly Lofton is an esteemed obesity medicine specialist at NYU Langone, who is here to share her expertise on GLP one. Doctor Holly Lofton, thank you so much for joining the coalition. Thanks, Doctor Shawnee, thanks for having me. I'm looking forward to this conversation. Yes, I'm super excited that you were here. Not a day goes by where someone doesn't say to me, what's the real deal with the GLP ones is I'm excited to have an obesity medicine expert on the show. Doctor Lofton, please get us started by telling us a little bit about who you are and what you do.

Thank you. I'm a board certified obesity medicine specialist, so that means I do everything for weight management, but not surgery like you do. So thank you for doing surgery. Let me offer a specialized diet all medications for weight management, and help people with their weight related conditions such as diabetes, blood pressure, etc. and I really feel that obesity is a lifelong condition, that even when someone's weight is normal, it's not cured. So I do follow patients essentially for life, keeping in mind they might need different treatments at different times.

I also do clinical research on many of the medications that, you know, on the market now and some that are in the pipeline. So we'll talk more about that later.

How GLP-1 Medications Work 1:57

But I'm happy to give the real deal about GLP ones today. Fantastic. So let's just jump right into it the GLP one. You know, people are familiar with some of the brand names Ozempic. Well Govee Zach Brown, moon gyro. Can you kind of give an explanation in simple terms as to how these medications work? So one thing it's really important to know is GLP one, which stands for glucagon like peptide one, is a naturally occurring hormone. Doctor Sean, you, myself, everyone listening and watching all makes GLP one from our intestines every time we start eating a meal and that GLP one goes through the brain and eventually tells us to stop eating.

It also has some benefits that it indirectly can help with fat cells shrinking in size by making patients respond more to the insulin they make. And also, it makes your stomach empty slowly so you digest the food that you eat or absorb the nutrients in that food. But those are what the GLP one medications do too. So in summary, they decreased appetite in the brain, make the stomach empty more slowly and hormonally, make our fat cells shrink indirectly by changing the way we process insulin. So these are all naturally occurring hormones we give back to the people a form of medication.

And there are different types. And we can go through the names going on to use for many things other than weight loss. I'm sure people are familiar with the use for type two diabetes. But now specifically we go, which is the weight loss version of a big is approved to treat fatty liver disease. Step down, which is the weight loss version one zero is used to treat obstructive sleep apnea. And there are many other indications or reasons people might use these beyond weight loss that are being investigated.

Well, thank you so much for providing some clarity on that. So I think that's a great segue into who should be on these medications. It seems lately from watching media that many people are on these medications, and a lot of celebrities have been doing endorsements. But when someone has concerns about their weight, how do you counsel them on whether or not a GLP one could be the right choice for them? Well, it's really important to know that these are FDA approved medications, and they should be coming from a well-versed prescriber.

You don't want to get them from your friend or your cousin. You don't want to get them from a source. It's unknown.

Who Should Consider GLP-1s 4:27

You want to have a conversation with the prescriber about how this may help you, but what's most important is that it's determined that you don't have any contraindications or any reason that taking it would be dangerous. So the first group of people it's not for are those who have either personally or had a family history of medullary thyroid cancer. And this is a very rare condition maybe affecting going out every 15,000 Americans. But if you do have that history, these medications are not enough for you.

The next is other GI disorders. You can have more robust conversations with your doctor about it. But if you have problems with digestion or pancreas or gallbladder issues, it's really up to your prescribing yourself whether these are food safe for you, because they might be some different things with dosing or may not prescribe it at all. So that's a great first thing. Is it going to be harmful. And then most people the answer to that is no. And the next thing is how could it help me. So for weight we look at body mass index, which you know, is an imperfect measure.

If looking at someone's weight or risk of morbidity or even, death mortality. But it is a simple height weight ratio that we use to determine who's a candidate for medications. So those who have a BMI over 30, their candidates, those who have a BMI 27 to less than 30 with a weight related condition, like blood pressure or heart disease are candidates. And it's also important to know that some of the GLP he wants are indicated for our adolescent population, which means those aged 12 to 17. But right now it's that balance.

Your appetite is indicated for those who are 18 and up, whereas we go obese indicated for 12 and up. So it's important to really make sure that you had those conversations with your provider to see who may be a candidate. And who is not really for. Thank you. When we talk about side effects of the medication, some that have been talked about a lot are the GI side effects, nausea, vomiting, diarrhea, constipation. What are your thoughts on that? And would you say that the side effects tend to get better with time?

If people are able to stay on those and stay on the medication for a period of time? Well, one thing I would tell you, this is a conversation I have multiple times a day. I see patients for weight management over 20 of them a day, and I also involved in the trials for these medications. I mean, using them before they were on the market. So I give you the answer of what was presented in the trials and then what I see clinically. So you're absolutely right. The most commonly reported side effects are gut related because these are gut hormones we're giving back to people, in order nausea depending on the drug.

Next is constipation or loose stools. Vomiting can be a side effect. But if you look at the numbers, none of these are reported more than 50% of the time, which means most people do not have side effects.

Common Side Effects and Tolerability 7:18

And I think it's worth reporting. But those who do are very vocal about it. So that's why you hear a lot about these side effects. So it's important to know that you can have mild side effects, mild nausea that is bleeding and goes away. You can have moderate nausea that last hours. And you can have severe nausea that leads to vomiting. And you feel horrible all day. So it's important to look at the severity of the side effect, not just whether it's present or not. And depending on the drug. Let's just start with nausea.

At the highest dose, we go with not just for about 44% of the time. So not quite 50, but 40 for what I see clinically is on these drugs. Patients will have some nausea at some point. What do you think is bad enough to report? Pick up the phone and call a doctor? It's not usually, but some people will have severe nausea. They have make a phone call or send a my chart message for. So it's about having that communication with your prescriber to determine what's serious and what's not. What are some of the other, side effects or things that can happen?

Other things that people have been talking about are quote unquote, ozempic face the concern for, decreased muscle mass or sarcopenia and also alopecia. So one thing that we do, we talk about side effects is when when you have seen many clinical trials, there's a long list of side effects takes over a whole page. So anything that reported more than 1% needs to be put in the trial. So we're aware as providers what these are, but we don't usually talk about the ones that are 2% or 1%. And the things that you mentioned are more in the 1 to 3% range.

I'll start with hair loss. These medications are used for weight loss, and weight loss alone with or without medication can cause hair loss. The body really can let go of what it considers to be not tissues. Essential tissues like hair. When you're losing weight. And sometimes that has to do with how rapid the weight loss is. What's important advice for a patient is hair loss. We make sure the nutritional status is optimized, that they're eating protein, drinking water, that they're not getting low and iron because those nutritional deficiencies can also lead to hair loss.

And then if it's severe, not treated with those type of treatments, then we may discontinue or discontinue or lower the dose of the medication. And then moving on to well the next one is said with muscle loss. So there's a lot of talk about muscle loss with these medications. We know that when you lose weight, we don't only lose fat cells. Our goals are to shrink the fat cells. But that does come with some decrease in muscle composition as well as the size of the muscle. We have to keep in mind muscle is.

Let's think about a bicep. It's not fully muscle tissue. There can be fat within that muscle tissue. So when you're losing weight losing that fat makes it seem as if your muscle size is going down. But there have been definitely reports, and most people will lose about 3 pounds of muscle for every 10 pounds they lose. So that's 7 pounds of fat to 3 pounds of muscle is the usual ratio. And they've done some analysis of this. And people who are taking the group ones are not losing more muscle mass.

As someone who's losing weight without the GLP ones. But that being said, it's important to make sure you're eating your protein during your resistance training and things like that. And there was a third side effect you asked me about quote unquote Ozempic vs Ozempic face. Yes. So again, these drugs cause fat loss. And when we gain weight, we gain weight all over, including in the face. So sometimes if someone's have a a weight condition that can appear some of the face, you have a nice baby like face and then we lose fat there.

The skin is still there, but the fat is gone and that can make the face look like it's sagging. We've been seeing this for a long time in our patients with bariatric surgery. Even in our office, they lose weight and they say, now I look older because I have wrinkles, because the fat going, I'm nowhere to go. What can we do? We offer the fillers sometimes to take up that space, but it's not as if it's making you age prematurely.

Hair Loss, Muscle Loss, and Ozempic Face 11:15

I will tell you that having decreasing your fat mass, does decrease inflammation all over the body and can be useful for making your lifespan actually longer. And the other thing, if you think you don't like the way your body looks at any part with the medication, we can always slow it down. If we want to slow down how quickly you're losing weight. We can adjust doses and things like that. Thank you so much for covering those areas that come up a lot. I wanted to find out the real deal about maintaining weight after cessation of the GLP one agonist.

Yeah. So what we're talking about here is what happens when I stopped taking the medication. And as I mentioned earlier, I think you treat weight for life. So we're always looking at what is the best option for any individual at the given time. Let's start with the clinical trial. So the studies show that when patients start GLP you want to get up to the highest. Those average weight loss is about 20%. So that's a 200 pound person losing about 40 pounds. And they did a trial that was very sneaky.

They kept some people on the drug and they lost more weight, maybe another 5%. And those who were unknowingly given a placebo or fake drug, but continued their lifestyle recommendations, gained about 14% of that weight back, so they were left with a 6% net weight loss at over a year and about a year and 20 weeks a year and a half, whereas those who continue the medication had sustained weight loss. The reason for this is the medications are giving you a physiologic benefit. They're decreasing appetite.

They're keeping your fat cells a smaller size or making your stomach empty slowly so you're forward less. And when they're taken away, that's gone. Now, with our best effort to die in exercise, we can maintain some weight. Like this said, there's 6% now. Weight loss over a year and a half. But if you're hungry, what you will be after losing weight if your fat cells can now because they are gland get bigger than weight gain tends to occur. So we do expect people to regain weight after we discontinue the medication because we're not taking it anymore.

Just like if we stop a blood pressure medication, the blood pressure tends to go back up. That being said, I do get everyone who wants a trial off to see what happens because it is possible to stop the medications and not gain weight. But we don't really have a lot of data now on how to predict who those people might be. And you'd be surprised. It's not always the one who's an ultra marathon runner and eating caloric restriction. Some people just maintain, you know, they're 70 years old using a walker.

They don't eat it and they don't. You can lead again. On the converse, I've seen patients do everything right, diet and exercise and regain all the weight. So that's, individualized. So what are your thoughts?

What Happens After Stopping GLP-1s 14:03

I agree that obesity is a chronic condition and that there can be different things that we use to treat it. Kind of multimodal therapy. Yes. What are your thoughts on the combination of bariatric surgery and weight loss medication? I'll start by saying that in my practice I have used it pre operatively and for patients above a certain BMI, because we know that beyond a certain BMI, surgical risk goes up. Right. And so I've used it in that way with good results. And then sometimes for patients who've had, weight loss surgery who are many years out that are because of the chronicity of obesity, having issues with rate regain, adding those on.

But what are your thoughts on kind of the multimodal approach to obesity? I'm really glad you brought this up, and I'm glad that we're here having this conversation together as a bariatric medicine and bariatric surgery, talking this out because there definitely should not be an us versus them mentality either or. Right? We need to adapt to get the best result from the patient. I wholeheartedly accept what you've done in preoperative GLP one use as well as post-operative GLP one use. Because this is in line with physiology, we know that if someone has a sleeve gastrectomy today at noon, that when we wake them up at 130 from their anesthesia, their GLP one level is through the roof because we've cut their stomach and in croutons, which is what GLP ones are.

Those gut hormones are start to release. And that's why you wake patients up and they don't have diabetes anymore automatically before they've lost weight. That's why you wake patients up when they're really not hungry, because their natural GLP one is through the roof. Now, we know that over time, a year or two years, even four years, that level can start to come down that the patient is making inherently. So we give GLP one back in the form of a medication to continue to get weight loss or avoid the gain for that person's health and longevity.

And I've actually done some research on this. We looked at patients who had gastric bypass and they're gained weight.

Combining Medication with Bariatric Surgery 16:21

And we gave them either, everyone had the dietitian recommendations for exercise or we gave some people a GLP one and we gave some people it possible no one knew what they were getting. The placebo group, who just had the lifestyle but were well supported, gained 2% of their way back over a year. Those who had the GLP one, in addition, lost another 9% of weight. So this is physiologically helping patients get results. Beyond what they can with lifestyle alone. So I definitely support this. And I want to tell anyone out there dealing with weight regain after magic surgery to not be afraid to go back to your doctor.

I and extremely I find it unlikely they will chastise you, but try to find an answer for you as well, because there also could be some anatomical issues that need to be investigated. So don't avoid your bariatric surgery if you have weight regain, but embrace it. Thank you. Please return this evening. Well, thank you so much, doctor Holly Lofton, for, providing real expertise on what is a very salient topic for people that have enjoyed meeting you on the coalition. What is the best way for them to get connected?

I think it would be great to look at my Instagram, which is at doctor Holly Lofton. I'm also on Twitter doctor at doctor H. Lofton. That's Dr. Holly Lofton, and I share some insights on trends I'm seeing with my patients and new scientific advancements. So that's a good way to get some new information. Absolutely. Well, thank you so much, Doctor Lofton. I hope to see you on the show another time. All right. Excited. Thank you. Thank you. Well, everybody, thank you so much for tuning in to another impactful episode of The Coalition.

I'm your host, doctor Shani Belgrave. I am a bariatric and minimally invasive surgeon in Atlanta, Georgia.

Where to Follow Dr. Lofton and Closing Remarks 18:09

I'm also the founder and CEO of Omega Bariatric and Wellness. You can stay connected with me at Doctor Shani belgrave.com. Very special thank you to doctor Holly Lofton, a renowned obesity medicine expert at NYU Langone. You can get connected with Doctor Lofton on her social media. Make sure you share this episode with friends and family to raise awareness about obesity and the latest in treatment. I'll see you next time.