The Truth About GLP-1s for Weight Loss

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:11):
Hey, Dr. Koehler.

Dr. Koehler (00:13):
Hey Kirstin.

Kirstin (00:15):
You know what we're talking about today?

Dr. Koehler (00:18):
Oh, please tell me.

Kirstin (00:19):
You already know we are talking about GLP-1s, semaglutide, tirzepatide, whatever you want to call these things because they're hot right now and they're not going anywhere anytime soon. And we offer them here at our office. So I want to ask you a little bit about them.

Dr. Koehler (00:37):
Sure. Fire away.

Kirstin (00:39):
Fire away. All right. So in our office we have a nurse practitioner that oversees our weight loss program, and then you are in charge of her and her patients and all that good stuff.

Dr. Koehler (00:53):
Yeah.

Kirstin (00:54):
A lot of people call these GLP-1s, Mary Emma hates this term, but a lot of people call them the skinny shot.

Dr. Koehler (01:02):
Yeah, I'm not a fan of that either.

Kirstin (01:05):
Okay. What are these injections and why do people call 'em the skinny shot?

Dr. Koehler (01:09):
Well, because it is a shot, and these drugs were originally developed for patients with type two diabetes. And just like a lot of things in medicine, drugs are developed for one purpose, and then when we start to study them, we notice there's other side effects and things that happen. And in this particular case, one of the side effects of course, is some weight loss. And that's without people even changing anything that's just taking the shot. And so of course that's how it's become the skinny shot because it'll help you lose weight without actually really not having to do much of anything. And it's being kind of promoted as that. And of course, as you know, I mean we're struggling with an obesity epidemic in this country. I mean both in our youth and in our adults. This is something that's really become very, very popular.

Kirstin (02:08):
Is there a difference between the two most popular, the semaglutide and tirzepatide.

Dr. Koehler (02:14):
Yeah. I mean they're both GLP-1 agonists, but then the tirzepatide also works on another hormone, the GIP. It actually is a little bit more effective for weight loss and for people that maybe require more weight loss because it has two mechanisms of action instead of just the one. For people who need to lose a more significant amount of weight, that might be a better choice. Those are the semaglutide and the tirzepatide are the two kind of big weight loss drugs that we have right now.

Kirstin (02:47):
So you kind of mentioned that tirzepatide would be used for people that need to lose a larger amount of weight. So does one work better than the other or it just kind of depends on your needs?

Dr. Koehler (03:00):
I think a little bit depends on your needs and then also on your pocketbook, because the tirzepatide is more than double the cost. Even when we get it made from compounding or we get it from compounding pharmacies, so we can get it less expensive than the brand name drugs that you would get through the pharmacy. It's the same drug, but you get the brand name drugs. But even when we get them compounded, the tirzepatide is definitely more than double the cost. It's the latest, it's the newest one that's only been around since 2022, I believe. The newer it is, the more expensive it is. But yeah, I would say that for a vast majority of people that are getting on this, the semaglutide is fine. They all have their own little side effect profiles and some people may experience more or less with one drug or the other, but they both kind of suffer from the same kind of side effect problems.

Kirstin (03:54):
You said tirzepatide came about and about when did you say 2022?

Dr. Koehler (03:58):
2022. I think it was FDA approved in 2022 I think.

Kirstin (04:03):
Have the OG GLP-1s been around a lot longer than that, or are they newer as well?

Dr. Koehler (04:08):
Well, they came out, I think it was really just, it was before 2010 when the very first ones came out, but it wasn't really until Ozempic that the whole issue of weight loss, and that's when it really ramped up as a weight loss medication, not just a diabetes medication.

Kirstin (04:30):
How do our patients benefit from these medications? Or do you have surgical patients that use these meds or are there people that seek out just the weight loss component thing first?

Dr. Koehler (04:45):
Well, I'll tell you the way that this has really benefited us, and probably the biggest reason that we've added this to our practice is, well, first of all, in the past I would have people come to see me for a tummy tuck. And when we would meet with them in consultation, it would be clear that they would benefit from a tummy tuck. But they also have a weight problem. And we've talked before, liposuction is not a weight loss treatment. Tummy tucks are not weight loss treatments. Certainly we're going to be removing fat and we're going to be removing skin. And yes, there will be weight loss, but it's not a treatment for that. It's it's very little weight loss considering what all we are doing. It's more of a contouring procedure. So the problem that we would run into is sometimes we'd have people that they were obese or maybe even more than obese, a little higher than the obesity category.

(05:42):
I won't say morbidly obese, but they're definitely getting up there and they want to improve their looks. And we were having to turn those people away from tummy tucks because, not because we didn't want to do their, well, we don't want to do their surgery when they're at that point because one, their complication rates for blood clots, wound healing problems, infection, all these things go up when their body mass index goes up. And some of these people have really struggled with weight their whole lives, and they're frustrated and they do want a solution. And so this is why we've added this to our practice because we would like to ultimately get these people a long-term solution, not like, oh, we got a bunch cut off and sucked out and you're a little bit smaller, but by the way, in six months you've got all that weight back. What we want to do is get them into a healthier weight and do the procedure to get them looking great and then keep them there. And so that's really been the impetus behind adding these GLP-1 agonists to our practice is to just help those people who've really struggled with weight their whole lives get to a place that they can be happy.

Kirstin (06:52):
So if you're someone who doesn't have a lot to lose, maybe just 10 or 15 pounds, is that someone who would be a candidate for this?

Dr. Koehler (07:01):
Well, my answer is no. But I mean, everything's qualified, right? 10 or 15, if somebody came to me and this, I want to lose 10 pounds. I mean, there's a lot of questions that go before that. I mean, have you done anything? Have you tried to modify your diet? Have you tried doing regular exercise? And if all those are no, then the first thing is like, Hey, there's no magic. And I guess that's the big misconception, and I like to just cover this when it comes to the skinny shot, which I really don't like that term either, I mean people, we all want a quick fix. I mean, myself included. So I'm not criticizing other people. I mean, we all want something that requires very little effort on our part, and we can get a shot or a pill or something and voila, we're better.

Kirstin (07:51):
Magic.

Dr. Koehler (07:52):
Magic. And yes, as I told you in people in the studies for diabetics who didn't change anything except for take this medication did lose weight. But when we start using this truly as a weight loss medication, you have to use it hand in hand with changing your diet and doing some exercise. If you really, really want to see some results, you might lose a few pounds, but you're maybe not going to lose the weight that you want to unless you're also committed to the other part of it. So I guess the first kind of misconception is just this is not a magic bullet. It's got to be done with some other things. So back to your other question is if I have somebody who just has 10 pounds to lose and they've not done anything to even make an attempt to do it on their own, I mean, my first thing would be like, you know what?

(08:44):
I think you should spend your money on a personal trainer, maybe get your nutrition down. And you got to do something that's sustainable, that's the other thing, sustainable long-term solution. We'd all love to lose all this weight in one month, two months, whatever. But really to do it sustainable, you need to do it slowly over time and get to where you're going to be and then maintain it. When these drugs were, so originally were all FDA approved just for diabetes. Now there are several of them that are FDA approved for weight loss like Wegovy and what's the other one? Zepbound. Anyhow, those are FDA approved for weight loss. But if your insurance is going to cover that, you got to meet certain criteria, and you've got to have a body mass index of greater than 30, which means you're obese, or it can be a little bit lower.

(09:36):
It could be like 27, but then you have to have some other health things like high cholesterol, hypertension, like other medical problems. So if you have 27 plus some other health things, you could also qualify. So if you're going to pay for it through insurance. Now, if you're doing it through, let's say our clinic and you don't meet those criteria or you do, but your insurance doesn't cover it, we can still do that. And we use the compounded, which is less expensive form. It's the same drug, it's just generic kind of thing. Our general criteria is people that are obese or overweight, those are the standard patients that we're typically treating. And also we tend to not prioritize, but the people who are the best candidates are the ones that have maybe struggled their whole lives. They've tried multiple things, they've not been successful. And then there's another kind of group of patients that this is helpful for that people might not realize.

(10:36):
But women that have polycystic ovary syndrome, they can be actually a much lower body mass index, but they have issues with fertility. And PCOS is a whole nother problem for another day to discuss, but it's a metabolic type thing. And these drugs can be helpful in getting the weight down, but also helping these women with the fertility issues that they may have. So we will often use these drugs in conjunction with other medications for that condition to get them feeling good and hopefully help them with fertility and other things. And we're not a fertility clinic, I'm just saying, but that's part of the problem that women can experience with polycystic ovaries. The other thing is patients that really struggle with visceral fat, which we've talked about I think before in our previous podcast, but sometimes you carry weight under the skin. That's the kind of stuff we can suck out with liposuction, and then there's weight that we carry that's on our intestines, and that's the stuff that is really resistant to diet and exercise. It tends to be the last fat that we lose, and that's where these medications come into play because they actually help. They promote your body to burn off your fat stores, and in particular, that visceral fat. So it can be used in those circumstances as well.

Kirstin (12:00):
What are some of the typical side effects from GLP-1s?

Dr. Koehler (12:04):
The most common one you hear about is nausea, vomiting. People get on them, they're like, Ugh, I just feel so terrible. They just feel sick. They might feel fatigued, maybe headache, maybe diarrhea. But main one is nausea. That's the big one that people don't like and it doesn't feel good.

Kirstin (12:25):
At this office, do we do things to mitigate those side effects, or is it just something that your body kind of gets used to over time anyways?

Dr. Koehler (12:33):
I think you do get used to it, but the way that we deal with it is we start off with a low dose and then slowly increase the dose as you tolerate it. And so the frustrating part is when you start with a lower dose, you might not start to see some of these effects of weight loss. You could be on the drug for two, three weeks and you'll be like, well, I haven't lost anything. I haven't lost anything. Well, if we hit you with the higher dose, which you absolutely probably would lose weight much more quickly, you'd also be feeling awful. So we'd start to ramp it up and then when we get to where we've got the progress we're seeing, then we can hold it there.

Kirstin (13:13):
Okay. Is there a certain timeframe when people will normally start to see results, or is it kind of patient dependent?

Dr. Koehler (13:20):
A little bit is patient dependent, but I mean, you typically are seeing results within two, three months, you're going to see weight loss. Actually, with some of these drugs, I mean, the tirzepatide, probably within a few weeks, it won't be massive weight loss, but you're going to start seeing it happen pretty quickly. But definitely by three months you should see it. And for people who have a lot of weight to lose, you may need to be on this for a year or more to really see the final weight loss that you're going to get with taking that. And obviously, diet, exercise.

Kirstin (13:59):
Have we seen benefits to these drugs besides weight loss?

Dr. Koehler (14:04):
There are reports that, because this does work on the brain to help with that whole in the hypothalamus on just the whole hunger, cravings and stuff like that, there appears to be also some effects on those same centers of the brain that affect those cravings for other things like alcohol and nicotine. So I mean, it's not that it's primarily used for nicotine addiction or alcohol addiction, but I think they're also seeing some benefits. So for people who may be overweight and may also be struggling with some of these other things, it may help them to break other habits in the process. There's some thought that it might be cardiac protective because it does help with just generalized inflammation in the body, and so there could be potential cardiac benefits to patients. And it also can be useful for fatty liver disease and kind of helping the progression of fatty liver disease. So there's other things that they're looking at and that there's potential benefits for which I think that's good if we can get those other benefits.

Kirstin (15:13):
Yeah, for sure. How are we sourcing our medication?

Dr. Koehler (15:17):
Well, we got a dealer.

Kirstin (15:23):
A good one.

Dr. Koehler (15:23):
Good one. She's really good. No, we have companies that we work for compounding pharmacies, and it's a simple shot. It's once weekly typically that you're giving yourself a shot, and Mary Emma, she can show you how to do it. It's not an intramuscular shot. It's like just subcutaneous. It's a very, very simple shot to give yourself.

Kirstin (15:45):
And the needle is bitty teeny tiny.

Dr. Koehler (15:47):
Yeah, it's ridiculous. It doesn't, now, the one advantage of the prescription ones like the ozempic, it comes in a little injection, like an EpiPen kind of thing, and you twist it to get to the dose you want, and you can adjust it as you increase your dose, and then you just put it on there and push the button. Then it pops, gives you the injection very, so that is kind of nice, but really it's still, it's not a bad injection.

Kirstin (16:13):
If people are afraid to self-inject, they could always come see Mary Emma and get a little tutorial and have her do it a couple times before they take it home and take it over.

Dr. Koehler (16:23):
Might just have to have a relative or somebody to do it too. If you're afraid of doing it to yourself. It's more of the thought of sticking a needle in yourself. That's probably, if you have somebody else do it, it's easy because it really, it's not a painful injection.

Kirstin (16:37):
True. Okay. So have you tried them?

Dr. Koehler (16:43):
Yes, I did. Yeah, I did. It's been a while actually. Oh, it's a long story. But yeah, was after my father passed, and there was a few things, I was like, you know what? I'm just not in the shape I want to be, and I was kind of on this, I wanted to ramp it up and lose some weight. I was heavier than I wanted to be, and so I did it for a short period of time. In fact, when I quit, it was when my wife said, people think you might have cancer. Because I was also doing diet and exercise. I was all full on, and I dropped quite a bit of weight, and I was like, yeah, no, I'm not looking too good. So yeah, I tried it. It works. And actually, I was doing everything, so I probably would've been just fine working out diet and exercise, but I kind was like, yeah, I want to ramp this up.

Kirstin (17:41):
Yeah.

Dr. Koehler (17:41):
I did. I tried it, it works. I didn't have any problems with nausea. The medication works fine. I mean, you can drop some significant weight. I will share something though that we talked a little bit about side effects, but something we really didn't touch on that I think is actually really important, which is actually there's bodybuilders that are using this when they compete and they'll bulk up and in the process of bulking up as they're getting their muscle mass, they're eating tremendous amount of calories, lot of protein, whatever, and they are really, but they also put on body fat. I mean, it's hard to bulk up and add muscle mass with, and at the same time lose body fat because they kind of work against each other. So bodybuilders will bulk up, and then when they're getting ready for competition, then they drop, they'll drop that body fat and they cut a lot of the carbs and fats and everything else.

(18:35):
Well, I've been hearing about a lot of bodybuilders are starting to use these drugs to cut their weight for competition. But something very interesting that everybody should know is that when they're looking at these patients and doing body composition, not the bodybuilders, but if we look at patients that are on these drugs and follow them with scans and checking their body composition, what we're finding out is that, yes, you lose fat, but you're actually losing a pretty significant amount of muscle mass. And so this is kind of a big deal because I mean, yeah, you'll probably lose muscle mass with weight loss in other ways too, but it's a pretty significant, like 50% I've heard as high as 50% of the weight loss is from loss of muscle mass. It is very important if you are taking these drugs for weight loss, that you are for sure getting your protein requirements, and you really should be doing something in terms of strength training, weightlifting or something to try to stimulate muscle mass because you're going to lose some regardless. But you don't want to lose all that muscle mass. And I have seen people that just after they've lost weight, they don't look healthy because they've lost muscle mass and fat, and they just, yeah, they're thin, but they don't look healthy. So we want to try to make sure you always are healthy.

Kirstin (19:59):
So how can we help patients here after they've lost weight and have loose skin?

Dr. Koehler (20:05):
Well, we got lots of solutions for that. Well, a couple things. Not everybody's going to have loose skin. And so the one thing we may have touched on it before, or at least we've talked about before, the whole ozempic face thing. Ozempic face is what you see in anybody that loses a significant amount of weight. Ozempic is not changing your face per se. But yeah, when people lose a pretty significant amount of weight, we do see changes in their face. There's plenty of studies that show as we get older, especially people who are a little on the heavier side, their faces look younger than those people that are underweight at. So if you're in your late fifties, early sixties, and you're a little overweight, you're going to look more youthful if you're overweight, and vice versa. If you're underweight, it'll makes you look older. But anyhow, yes, you could be left with loose skin. A lot of things determine that, like just your genetics, your skin tone and elasticity, your just general nutritional status. Some people, when they lose weight, their skin retracts nicely over time, and other people, yes, are left with loose skin, and that's the wonderful thing. We have tummy tucks and arm reductions and thigh lifts and lots of different procedures and face lifts, things that we can do to address these problems after weight loss.

Kirstin (21:25):
So once people reach their goals, is there a maintenance plan or do they quit taking the medications, or how does that work?

Dr. Koehler (21:35):
Usually, once we hit their goal, then we'll taper down to right down to the very lowest dose, and then might even go to alternating weeks instead of once a week to get people just to keep in their rhythm and then eventually just come off completely. If they start to relapse, then we may consider introducing it again, but we may not have to go to the same lengths. It might just be like, okay, hey, we just need to do a little short treatment course, get you back on track. But the goal is not to be on this long-term. The goal is to kind of help you and really where the benefits come in to make lifestyle changes along with taking medication, see those results, realize those results, and then do something that is sustainable. We talked about it before. You need to have a workout plan. You need to have a nutritional plan. If your goal is just to take this drug to lose some weight, and then as soon as you come off of it, you absolutely are going to put all that weight back on. If you didn't do any of those other things that we talked about, it will come back and then you're going to be back on it again. So that's why it's not just a skinny shot. It is a skinny shot, but it's not a skinny shot long-term solution unless you're doing the other thing.

Kirstin (22:52):
So if somebody's interested and wants to consult with us, what do they need to do?

Dr. Koehler (22:58):
Just call the office, ask to speak with, or that you'd like a consultation with Mary Emma to discuss weight loss, and she will reach out to you and she can help get on the journey.

Kirstin (23:10):
That's right. All right. Do you have anything else you want to add?

Dr. Koehler (23:14):
No. Have you been on ozempic.

Kirstin (23:15):
Mm-mmm.

Dr. Koehler (23:17):
Semaglutide? I mean, you're asking me personal questions. I thought I might ask you.

Kirstin (23:24):
You know what? I have been on semaglutide.

Dr. Koehler (23:26):
Oh, you have? Okay.

Kirstin (23:28):
Mm-hmm. I have.

Dr. Koehler (23:29):
Okay. Why don't you tell me your experience?

Kirstin (23:31):
Okay. I'll tell you my experience. Well, 2020 had me liking wine a little bit, so I said, Mary Emma, how about a GLP-1, so I don't want to drink wine every single night of my life. I

Dr. Koehler (23:46):
Is that bad? Is you stress that bad from

Kirstin (23:49):
No.

Dr. Koehler (23:49):
So

Kirstin (23:52):
This is the least stressful job I've ever had. Honestly. No, but I lost like 10 pounds.

Dr. Koehler (23:59):
That's awesome. It is a medication that works. There's no question. I saw definite like it works.

Kirstin (24:06):
Do you have a burning question for Dr. Koehler or me? Leave us a voicemail on our podcast website, AlabamatheBeautifulpodcast.com. We'd love to hear from you. Thanks, Dr. Koehler.

Dr. Koehler (24:18):
Thanks, Kirstin.

Kirstin (24:19):
Get back to making Alabama beautiful.

Dr. Koehler (24:21):
Working on it.

Announcer (24:23):
Got a question for Dr. Koehler? Leave us a voicemail at AlabamatheBeautifulpodcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic surgery, go to easternshorecosmeticsurgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you'd like to listen to podcasts. Follow us on Instagram @EasternShoreCosmeticSurgery. Alabama the Beautiful is a production of The Axis, theaxis.io.