The New York Times had an interesting article on Ozempic (and the like) as we get into the holiday season, and it’s worth the read. I think the fact that it’s a topic of discussion during the holidays itself speaks to how different these drugs are than any other, as they’re directly tied with relationship to food and body. Both of which are usually heightened during the holiday season, for better or worse. I’ve already written about these drugs - Ozempic, Wegovy (or semaglutide), and Mounjaro - a bit, and this probably won’t be the last time. My thoughts on them and how they’re used continues to evolve, largely because of what I’m seeing in patients at the hospital and the few private clients I have who are currently on the drugs.
There is still no end game plan
This is the part I can’t get over - once a patient has lost whatever amount of weight is deemed “necessary” (in quotes because this is also sort of subjective), what happens next? Staying on the drug indefinitely seems like a bad idea, given the impact it has on appetite and the fact that too much weight loss can lead to many other complications, like vitamin deficiency and malnutrition. But going off the drug will likely result in weight regain, as found in this study and likely many more. Having guidance on healthy nutrition and behavior change throughout the process from a dietitian may help prevent weight regain, but the large majority of folks on weight loss drugs are unfortunately not seeing a dietitian regularly. I will say this until the cows come home, but these drugs do not create lasting behavior change, nor do they heal relationship to food. I think part of the NYT article I linked above highlights that, with some patients asking their doctors if they can stop taking the drug around the holidays in order to enjoy eating, or eat more than the drug allows them to.
Less “food noise”
One thing I’m hearing from some patients taking Ozempic and the like are that they finally have less “food noise” in their heads and can think about things other than food during the day. There is noticeable relief when they talk about this, and I can’t not think that it may be helpful for them just from a quality of life standpoint. I find it interesting in that we don’t really know the psychological impact weight loss drugs have on people in this way, and how complex these things actually are beyond just reducing numbers on a scale. Whether the “food noise” comes back and when once people go off the drugs is also a big question I have, but sort of assume the answer is yes.
How are we addressing loss of muscle mass?
I recently had an 80+ year old patient with diabetes who was on Ozempic, and a few other diabetes medications, and his weight was what I’d consider healthy for an 80-year old. He noticeably had at least some mild muscle wasting, and it got me really concerned not just for him, but really everyone on weight loss drugs who may be losing muscle mass (and aside from the fact that no 80 year-old should be on a weight loss drug). I’ve talked a lot about how we lose muscle mass as we age, and how important it is to maintain that muscle mass so we can do the normal every day things we enjoy as we get older. It’s serious business, and very hard to do if we’re not eating enough protein and doing resistance training. I will also say that most people I’ve spoken to who are on a weight loss drug don’t know that the weight they’re losing may be muscle mass, and how minimize that with nutrition and movement. In addition to that, most are not eating enough protein simply because their appetite has dropped too much. This is going to end up being a huge issue down the road.
What is success?
The “success” of weight loss drugs recently have shown how easy it is to lose weight when you take them as directed and have the predictable changes in appetite. For some people, this is life-changing. But, I do say “success” in quotes because the number on the scale only says so much, especially without accounting for loss of muscle mass, malnutrition, vitamin deficiency, GI complications, how lasting the weight loss is, and a still-messed up relationship with food.
Seeing an RD beforehand, and a note on body autonomy
Education and counseling with a dietitian before taking a weight loss drug may set patients up for more success if they still chose to take them while working with RD. Here I’m defining success as developing lasting behavior change, improving relationship to food, maintaining muscle mass while experiencing the weight loss the drugs result in.
I’ve talked about how I don’t really do weight loss counseling in my nutrition practice, and it’s still not something I really focus on because I think behavior change is more beneficial to long term health. Weight loss can be a side effect to behavior change, but that’s all it is. However, as someone who has never lived in a larger body, I don’t know what it’s like to feel like you don’t fit in with societal norms, and the undeserved shame that comes along with that in so many ways. I think everyone should have the autonomy to do what they want in and with their bodies, and know that the desire to lose weight is very real for a lot of people. The purpose in writing this is to present information as I know it and help anyone reading this learn more and make decisions as best as they can.
Very thoughtful newsletter today. Thanks!