Why weight regain is a predictable biological response after stopping GLP-1s

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1:02Subscribe at KevinMD.com slash podcast. Today we welcome Jessica Duncan. She's an obesity medicine physician. Today's KevinMD article is GLP1 weight regain while stopping medication leads to weight return. Jessica, welcome to the show. Great to be here. All right. So you're an obesity medicine physician, just tell us briefly a little about yourself and your practice. Okay. Yeah. I actually started out in my career as an anesthesiologist. I became obesity board certified a couple of years ago, started noticing in my anesthesia practice just an increased prevalence of patients with overweight obesity and really got interested in learning more about the disease process and wondering what are we doing wrong at the healthcare system? That was, this was becoming such a big problem. So I decided to shift out of anesthesia completely once I got board certified in obesity medicine and decided I was going to see if we could do it a better way. So I joined the company Ivy Health a couple of years back, became the medical director. Now I am the chief medical officer. We are a telehealth practice. We provide individualized integrative care.

2:02We do weight loss and hormone health and some wellness as well. All right. Your KevinMD article is about GLP1 weight regain and that is something when I talk to patients about GLP1s of a potential scenario that they may have to experience. What led you to write this article on KevinMD in the first place and then you could talk about the article itself for those of you to get chance to read it? Absolutely. You know, lots of studies were coming out and really talking about the weight regain after GLP1 therapy. I started diving in and when I started looking, I realized that a lot of the trials and studies that were being done, patients were on GLP1s and it was a very free prescribed standard reduced calorie exercise and then the medications and then they were coming off medications trying to continue kind of that very people prescribed, you know, reduced calorie diet. And so for me, seeing these studies and seeing weight regain was kind of like no duh, you know, this is what's going to happen if we don't have a whole spectrum of support, obesity as a disease, it requires a long term solution.

3:02So I really wanted to kind of talk about, you know, the nuances of prescribing the medication who should come off medication. These are things we need to start thinking about before we even start prescribing and then when we do think about who should and can come off medications, how do we treat them? What are we, what's their plan going to be? This is a lifelong therapy for some, for some they just need a lifelong lifestyle plan and so we have to support all of those things too. Not our fault is the healthcare system that we don't have the ability to do this. A lot of it is kind of built into the way the system is. It was just my way of advocating for looking at it from a different angle. So what actually does the data say about weight regain after a patient stops a GLP1? So the patient abruptly stops the GLP1, the vast majority do regain weight. There's some variability on how much they regain based on what medication they're on and sort of the types of ways that we are treating them afterwards. For the vast majority of patients who just abruptly stop and have no real structured individualized lifestyle support, they do regain medication. Some are able, they do regain weight.

4:03Some are able to maintain and I do have patients all the time that are able to maintain their weight loss, but it requires a very structured and individualized plan for them. So what exactly does that look like in terms of that structured plan? If a patient chooses to stop a GLP1, whether out of choice or because of cost, that's another reason why a lot of patients stop. So when you say that some patients do well after stopping because of this structured plan, what would such a plan look like? First of all, it starts when they're on therapy. It can't start after. So you have to start making those changes pretty much as soon as you start medication. This needs to be, I always say this, GLP1s are one tool or a toolbox. So you can't wait until you're ready to take a patient off medication when you start thinking about everything else, but it's very comprehensive. So it's a nutrition plan. It's a movement plan. It's a movement plan that works best for that individual patient's body and that they can keep up with and it fits within the constraints of their lifestyle. It's a sleep plan. It's a stress management plan and for a lot of patients, one of the most difficult things

5:04about coming off medication is the return of food noise, cravings and the appetite suppression has gone away. So really working on coping skills, sometimes that requires advising them to seek cognitive behavioral therapy. Lots of different ways of managing that, but it is a full spectrum, full plan. And I usually, typically, if I am and have made a decision with a patient that I'm going to just continue with therapy, we do it slowly. We're not going to abruptly stop a GLP1 medication and wait, it's usually about four weeks before the hormonal metabolic effects were often so does the effect on the food noise and the appetite suppression. We're not going to wait. We're going to start slowly decreasing the dose, slowly stepping up the lifestyle modification checking in, how is it working for you? What do we need to change and modify? It's an ongoing deceleration of dose and then we come off the medication and then we see how it goes. And from your experience, what are some of the common reasons why people eventually stop GLP1? Well, a couple of reasons and you had a big one.

6:06A lot of it is costs and I think there is also, and patients want to try and see what will happen when they come off the medications. I think there's a lot of patients who don't like the idea of being on lifelong therapy and they want to see if there are things that they can do to maintain. I'll say those are probably the biggest reasons that I find patients want to come off. And from the data, do we have an approximate number of patients who would regain some or alter weight back? And does that be exact number? But what kind of ballpark number are we talking about? I think that just to kind of be broad about it, the majority of patients do regain their weight back base on the data. And in clinical practice, I think depending on how it's done and how your deceleration plan is and your comprehensive plan, that can be a little bit more variable. And when you initially talk to patients about the potential of starting them on GLP1s, how does that conversation go? How do you let patients know that this is a long-term medicine and there is a potential for weight regain? How do you approach that topic? That has to start with visit one and I'll tell you a lot of my patients ask me right

7:08out of the gate. Is this something I'm going to need to stay on? Is this something I can eventually come off of? So we talk kind of about who I typically find our patients that need to stay on the medication long-term. So they have risk factors, they have known cardiac disease, they have certain risk factors where they would benefit from staying on medication. That's one category of patients that would stay on. And then I talked to them about their obesity trajectory, any genetic or risk factors. And we kind of start to make that decision almost before we even start the medication. And I give them an estimate of do I think that you are someone who may need to stay on this long-term. I want them to know that going in. And you know, for some patients, I think that it is reasonable for them to come off medication and try. But it's a conversation that you need to start day one. It's in that risk-benefit assessment that we all learn in medical school. It's really part of that primary visit. And then we can reassess as time goes on and follow visits and discuss how they're doing and their progress and how their metabolic markers are looking if this is something that we think is reasonable. Even if on day one, we think, yeah, I think it's reasonable for you to come off therapy

8:11at some point. Well, maybe something changes along the way. So it's an ongoing conversation that you need to have with patients. And you mentioned earlier that you don't abruptly stop GOP1s on patients. Give us an example of what a typical tapering protocol would look like. Yeah. So again, it sort of depends on the patient, right? But I certainly don't think that it's in the patient's best interest to be at sort of the highest dose of chest appetite, you know, say we worked around 15 milligrams and just abruptly stop. I think it's always a smoother transition to slowly decrease, you know, month over month. Kind of this, in a similar way that you titrate and accelerate up to max dose of patients eat it, I like to do the same thing backwards and really get them to a dose where they're not feeling such a strong appetite suppression anymore, where they're not really feeling such, you know, strong suppression of food noise and they feel like, hey, I'm almost doing this on my own. I think I'm kind of ready to come off. And again, for some, that's kind of titrating back down to starting dose. For some, that's a little bit of higher dose. But again, it's really all about individualizing and seeing where the patients at every stage

9:14along the way. So it sounds like a fair amount of counseling needs to happen before patients, of course, start GOP1s. I'm seeing on television, as you know, there are a lot of compounding pharmacies and a lot of different ways where patients can obtain GOP1s from outside of a physician's office. As far as, you know, do they receive the requisite amount of counseling for patients who see and add on a super bowl, for instance, or online and get GOP1s that way? Physician led care, provider led care is essential. So if you are using, you know, a company or a medical institution and you don't have access to seeing somebody like me, you're probably not getting the support that you need. You need to be able to access your provider when you have questions, have access to a support team when you have questions. It can't just be a prescription and wish you the best. It has to be that ongoing support. My practice is a telehealth practice, but we provide structured support unlimited video visits.

10:14You can come in and talk to me or someone on my team any time to get more information. We customize and guide your plan. If you're not able to do that or there's not a provider that you're able to see before you get that initial prescription, that's probably not the way that you want to go about your GLP1 journey. How about in a primary care setting? So obviously, I'm not an obesity certified physician, but in primary care doctors like myself, we prescribe a lot of GLP1. So in these counseling visits, in these follow-up visits, just tell us some of the main points that we need to hit when we're managing GLP1s in our patients. It's such a great question. So I think, of course, you know, you always want to go through the risks and benefits of the medication. Make sure it's the right choice for the right patient with the right long term plan. I think it's always important to give patients general guidelines on nutrition. And I find that patients are not always ready to hear a very individualized meal plan on day one, but that's something that, you know, I would always invite them to come back to get more information on. And I suggest small incremental changes always in everything in movement and nutrition in

11:15the way you sleep. I think sleep hygiene is essential and having a good solid sleep routine is something that we should always talk about with patients that are seeking weight loss care, whether that's through GLP1s or otherwise. And I think it's always important to hit the basic side effect expectations, inside effect management and primary care when you're seeing a patient for the first time. You don't want something to be caught off guard when they start experiencing nausea. And I think in general, patients like to understand the why and what should I do about it and what signals they need for me to come back in or seek emergency care. But you know, that's just kind of my general, my general playbook when I'm, when I'm starting seeing a patient and I have a little bit of limited time. And you mentioned nausea, of course, is one of the more common side effects. Talk to us more about that, what can patients expect, what are some other common side effects that patients typically receive when starting a GLP1? The big ones that I see a practice are primarily gastrointestinal. So it's usually two ends with spectrum. It's nausea and constipation that we deal with. I tried to manage those before they even start. So I'm giving tips on sort of preventing those from happening.

12:17So for example, really getting on a good solid regimen with really solid fiber intake supplementing if you need to, lots of hydration to prevent constipation from happening. And then the nausea really talking about listening to hunger signals, eating small intervals, really kind of starting out with high protein intake, lots of good fiber and making sure to space out your meals, eat smaller meals. And then of course, we see patients who do have some degree of fatigue. And then we have sometimes patients that will say they have headaches. So those are the common things that we tend to see in our practice that I always talk to patients about up front. So they know it's common. So I know that there are both injectable forms and oral forms of GLP1. So talk to us about the decision tree that you go through to determine which form is best for each specific patient. Yeah. And it's interesting because the GLP1 oral GLP1 pill will go be pill, I think has generated a lot of interest in our patient population and it actually signals to me that maybe the injections were a barrier to entry for some of our patients. So generally, I kind of talked to patients about their daily routine.

13:18So taking the pill requires just a little bit of extra thought in how you're going to take the pill requires an empty stomach, it requires just additional daily routine. So I like to talk to patients about what fits best with your routine. I think consistency when you're taking GLP1, whether that being injection or oral is very important. So whatever is going to work best with your lifestyle, if you are able to do a weekly injection and if you don't mind, you know, the injectable form, and it's not difficult for you to remember every week, then that might be the one for you. Do you travel a lot? Is it going to be hard for you to travel within injections? That's one thing that we think about, but really it's whatever fits in your lifestyle in a way that makes it consistent for you is the best choice for that patient. Early on you talk about what to do if a patient does regain weight after stopping GLP1. So what are the options for patients then? Certainly. You have to do a full assessment and sort of see and try to dive into the reasons why that might be occurring. It's always possible to revisit the lifestyle modifications and other changes that you've made with the patient and see if there's things that need to be tweaked that fit better

14:20for them. And of course, it's always an option to go back on a GLP1 or other medication. I kind of have, and it's okay to fail, so to speak, mindset, it's okay if we need to restart therapy as long as we know what the expectations are going in after coming off medication in terms of weight loss, I think it tends to be a little bit different the second time around, the way the medication feels might be a little bit different for some patients. As long as the expectations are there and the patient wants to do that, that's always an option. Remember, obesity is long term chronic. We have to be able to be adaptable in the way we treat it, but that's medications are otherwise. Part of the role of exercise when patients are on GLP1s, I understand that strengths training certainly should be emphasized because there is a possibility of muscle loss on GLP1, so tell us about the role of exercise while patients are taking GLP1s. I love my patients to exercise. I want them to move every single day, and I do love strength training. I think it's really good, not only for weight loss, but for long term weight maintenance, and of course, I can mention for maintaining lean muscle mass.

15:21I love walking. I think walking is something that most of my patients can do, and it really needs to be a combination of both. But again, it's really like, what's available to you as an individual? Where do you live? What's your weather like? You don't have a treadmill, and it's cold, but the majority of the year, walking is not going to be possible. I love resistance bands, so I'll always suggest to my patients in terms of strength and resistance training. Resistance bands, you know, can be found online pretty easily in your local sporting goods store. That's a great way to do resistance training if you're limited to staying in your home. Most people can make modifications there, but it is absolutely an essential component of any weight loss plan, not just on a GLP one. We're going to Jessica Duncan. She's an obesity medicine physician. Today's Kevin M.D. article is GLP-1 weight regain, why stopping medication leads to weight return. Jessica let's end with some take-home messages they want to leave with the Kevin M.D. audience. A couple of things unrelated to GLP-1s. One thing I want to let all physicians know is that it is never too late to change your specialty. Like I mentioned before, I was an anesthesiologist, now I practice obesity medicine, and I

16:25think that a lot of us, you know, we make our decision on what our specialty is very early on relatively and the scheme of our training. We choose something that might not be right for us. If you're passionate about something, if you love something, it's always possible to make a change. And then my second take home is when you think about your patients, always, always individualize your plan. Always think about obesity as a chronic disease and the way that we manage it is a long-term solution that fits that patient. And that's not just a standard reduced calorie diet, really think about that individual and what's going to work best for them. Jessica, thank you so much for sharing your perspective and insight. Thanks again for coming on the show. Thanks for having me. Thank you for listening to The Podcast by Kevin M.D. To share your story and appear on the show, visit kevonmd.com.