Doctors’ Discussion:
Ozempic for Weight Loss

This transcript was exported on January 8, 2024 -view latest version here.

Skincare can sometimes feel overwhelming, whether it’s finding the right products, ingredients, or treatments. There’s a lot out there, but not always for people of African, Hispanic, Middle Eastern and Eastern South Asian descent. That’s why I set out to educate myself and others so that we can all feel beautiful in our skin.

Hello and welcome back to The Skin Report. I’m Dr. Simran Sethi, an internal medicine doctor, mom of three, and CEO and founder of RenewMD Medical Spots and Skin by Dr. Sethi.

I am excited to welcome a special guest on this episode, Dr. Schonze Del Pozo, a board-certified internal medicine physician and Medical Director at East Sacramento Concierge. With over 15 years of experience in the medical field, she’s here today to share her insights on weight loss treatments and lifestyle practices for healthy weight loss and her own experience using Ozempic to aid in her weight loss journey.

Dr. Del Pozo, thank you so much for being here today and sharing your experience with medically supervised weight loss in your practice and your personal experience. You and your team at the East Sacramento Concierge offer personalized services for various conditions including medical weight loss treatments.

Can you tell our listeners about your practice’s approach to medical weight loss programs?

Yes, hi, thank you. So I like to schedule a consult with patients initially, and talk to them about where their goal weight is, what they’ve done in the past, but then really to go a little bit deeper into their eating habits and if they’re tracking what they’re eating. And then beyond that, I often will recommend an app that’s called Lose It because it helps them to see how many carbohydrates are in different foods and that’s really what we try to limit. I think that there’s been a lot of focus on overall number of calories in the past, but it’s really about looking at your carbohydrate intake. And so we look at that and I have them track that for a couple of weeks so they can realize that foods, two cups of spaghetti have 86 grams of carbs in them, which is very significant.

And then we look at different factors that affect their metabolism. A lot of people look at thyroid, A lot of physicians will test thyroid to see why somebody may not be losing weight, but it’s deeper than that. Sometimes they can have B12 deficiencies or hormone imbalances, especially as people age. And so I look at really optimizing all of those things first, and then we look at the next steps in helping them medicinally if need be.

What would you say is the percentage of people from that initial group of patients that you see for weight loss that move on to a medicinal approach?

I would say about 75% because if they’re coming to me at that point, they’ve tried other weight loss programs or they really tried different dieting techniques and they’re very motivated at that point to really focus on their weight loss.

And when you say medicinal approach, does that always mean that you move them onto a semaglutide type drug?

Yes. Before that point, say there are patients, so the other 25% where we may find say in a 50 year man who’s testosterone is markedly low, is borderline high, both thyroid and maybe has some B12 deficiencies. So we’ll talk about optimizing each of those areas first and hold off on starting them on medication. But if it’s somebody where we either don’t find factors that we can optimize or they have a significant enough amount of weight loss that they need to achieve, then we’ll use medications like Ozempic or Wegovy, semaglutide.

Perfect. Do you find that when you’ve done the workup that everyone who’s as you described otherwise optimized and motivated is a good candidate for semaglutide

In general, yes. For patients that we would be concerned as far as maybe not being a good candidate for semaglutide would be someone who has significant acid reflux, someone very prone to nausea because the medication really works by not only inhibiting appetite or lowering appetite, but also by slowing stomach emptying. And that’s part of the way that it helps people to feel full sooner, but that can worsen acid reflux. In those patients, we may try to make sure that we’re looking at factors that affect acid reflux and see if we can optimize them there, put them on a medication for acid reflux, but that would be the person I may worry about. The other thing that we worry about are patients prone to constipation because the medication has been known to slow bowel motility and so we really have to talk to them about good hydration and being on the right amount of fiber or medications that help them to not become constipated.

When it comes to the use of semaglutide, the most of the patients you’re seeing are non-diabetic?

Probably 80% are non-diabetic.

There are a lot of programs now online and I don’t think they’re honestly programs, but a lot of different vendors for semaglutide that offer the medication, but I don’t think they offer the kind of medical supervision and guidance that you do in your practice.

Have you seen people go through those programs and fail for some reasons or have side effects who have then found you?

I have. Part of the reason is that exactly that. They either have had the significant side effects of nausea, acid reflux, constipation, dehydration, and really that is because of lack of oversight because there’s not someone really focusing on that. And what we do is each week when the patient comes in, we weigh them, we talk to them about how they’re doing, how their appetite is, if they’ve lost weight and how the side effects are, and are they hydrating, are they making sure to eat enough protein? And so really, in that dialogue, in that time, you can often help them to get around the side effects so that they can continue the medication.

In others, we’ve found that they’ve been given the medication and maybe even brought up to the maximum dose, but again, because there aren’t the other support factors there, they don’t lose the weight or they find that they’re losing weight too quickly because you want to avoid that as well.

What would be considered a normal amount of weight loss per week?

I would say a healthy amount could be around two to three pounds. The issue with semaglutide is that you’re losing fat mass, but there is a certain percent of muscle loss as well, and that’s why you really need to balance that out and making sure that they’re on a very high protein diet. We have them on a B Complex as well because as you’re losing weight, you tend to become deficient and B vitamins, so we want them to be on a good B Complex, but if they’re doing well on a high protein diet, then two to three pounds I would say would be around a good more moderate weight loss.

Is that the same for both men and women?

It is. For women, they tend to carry more water weight, so what women tend to find, especially if there are really love carbohydrates, the thing that with semaglutide is that it helps you to avoid carbohydrates over protein and other foods. Because carbohydrates really make you feel very full and bloated, and fill up the stomach and because the semaglutide is slowing stomach emptying, if you eat the same amount in carbohydrates that you do in protein, you’re going to get full much sooner with the carbohydrates. So women in general, tend to crave sweets or really love carbohydrates, and so we find that they often will lose size or inches before significant pounds.

Okay. Oh, that’s interesting. And then do they sort of then go into a greater, I guess, fat loss stage later on, or do they start craving protein because the amount of carbs they’re eating, even though it’s limited now is making them feel bloated?

So for the first part of that, as far as the weight loss, yes, we tend to see that they may have weight loss in terms of pounds after more into the second month or third month, but in that first month, they’ll start to notice that their pants are starting to feel looser and they’ll start to feel like they’re not as bloated.

For the second part of that, it’s not about that they’re craving more protein, it’s just that when they eat carbohydrates, they feel very full and bloated and so your mind, it’s kind of like a feedback loop to where you then start to not want to have carbohydrates because you feel bad when you eat them. So some people will say, “I’m not sure about the medicine because I eat a hamburger and then I feel bloated, I feel bad.” And I said, “Well, that’s the point of the medicine is really to help in what you’re eating and your choices.” So if you go to a restaurant and you want some pasta, have a chicken breast and a little bit of pasta, but focus on the chicken first, make sure you get your protein in first, but then have a few bites of the pasta more for pleasure, but it’s a negative feedback loop really to where each time that you eat, say a loaf of bread or something like that, you’re going to feel bad, so you don’t want to do that in the future.

That’s something I did not realize about the medication and I’m so glad that you’re describing it the way you are because you have the experience of treating so many people. My next question was going to be what are some of the lifestyle changes you advise patients to make while they’re on this journey?

So what I tell them is that the medication is really a tool to help with the weight loss because it can be so difficult, especially people again, that love food, that love carbohydrates. Those people have a very hard time losing weight because the craving, and so what I tell them is to use it as a tool basically, to lose the weight, to help control those cravings and their behaviors, but during that time to establish new food patterns that instead of when you go to Starbucks in the morning and you have your mocha and your scone, and something, you’re ordering the egg whites instead. And so after you’ve done that for months, then you get out of the pattern of wanting to always have something sweet in the morning. So you’re using that time to really establish new patterns of eating that then you can follow once you’re off of the medication.

I think that, that’s one of the things that, again, programs that are purely online and don’t really have a direct connection to a physician can lead to so much failure and honestly, a lot of myths and misconceptions around the use of medications like semaglutide. Because they’re just not being administered with the proper monitoring and guidance as you go through that treatment plan. When you treat patients, is there a certain age group that you think has better success with this and also making lifestyle changes or a certain gender?

I’ve really seen it work equally well for people. I’ve been surprised at the number of men in their forties, thirties that have come to me and it really made an amazing difference for them. I have a lot of women of all age groups and I think some people fear treating people maybe who are in their seventies, and I think that, that’s unfair because if you really are monitoring them closely, they can really get a lot of benefit from the medication as well. I’ve seen it work very well for both men and women and for all age group.

Who is the youngest patient or what is the youngest age group you’ve ever treated?

I’ve had a patient who, or I have currently a patient who is 20 and just finished college but has had a really hard time also related to some depression and self-image issues, and it was something that it was actually his grandmother that brought him to me and ask me for help. So we recently started him actually on the Terzapotide, Mounjaro. He is only been on it for a couple weeks, but very excited and I could just see a change in him and with the hope that he had and his grandmother wrote to me later to say, “Just thank you so much for helping him. He really has a lot of hope right now and he’s needed this.” And so I’m really excited to start this journey with him and see him through this.

One of the things in medical training that at least when you and I went to medical school and through residency, weight loss or medically supervised weight loss is not necessarily I would say taught in most medical institutions at least when we were in training, but because it’s not considered or wasn’t considered medically needed. But I think that with weight loss and aesthetic treatments that I do in my practice, it’s really about bringing confidence to the patient and is it medically necessary? I think that’s open to discussion. I think it is, because it also with it brings a greater focus on your self-care and that is essential to honestly staying healthy. I have to say that it’s amazing that you are open to giving these treatments to people of all ages as young as people in their twenties to people in their seventies, because at any age that’s equally important.

Yes, absolutely. One of the issues around Ozempic was really that once it became known for weight loss, that’s when all the backlash really started in the news and the media. But this medication had been being used for years in diabetes. A lot of people felt like it wasn’t a good idea or it wasn’t right to use it just for weight loss purposes, but we want to treat people before they get to the point of lymphoma resistance before they get to the point of having diabetes.

Oh, absolutely. Weight loss is like you said, it prevents diabetes and hypertension, but it’s actually the only cure for type two diabetes. If you think of type two diabetes, having a cure that doesn’t involve just a suppression of insulin levels.

So now what are some of you brought up how Ozempic has become more popular based on Hollywood celebrities coming out and saying they’ve used it on weight loss. What are some of the common misconceptions you hear from people?

As far as negatives go, I would say, the big concern that this is taking medication away from diabetics and that then the diabetics aren’t going to get the treatments that they need, but I really feel that because it’s such an effective and safe tool for people in helping prevent diabetes, we really need to put focus there. There are other medications we can use in diabetes in somebody who say isn’t interested in weight loss and is just interested in medication, but I think it’s really important that we take a medicine that is very effective and safe and utilize it in prevention. So I would say that’s one issue is that out there was a lot of backlash at thinking that this was taking away medication from patients with diabetes.

The second thing is as far as there was what was called Ozempic face, I’m not sure if you’ve heard about that, and we do see that sometimes because if patients are losing weight too quickly and if they’re not eating enough protein, hydrating enough, getting enough vitamins, then yes, you can get to that very gaunt look. But if you’re doing things right and at a good pace, then you’re going to do well. So that’s why you don’t want to be too aggressive because not only is it not healthy, but from an aesthetic look, you’re going to have effects. You need to do things more smoothly. So I would say people worry just because they’ve seen people who get that quote “Ozempic face,” but that’s not just because the medication, it’s because they weren’t really monitored during their weight loss pathway.

You’re right, again, that goes back to if you’re using this approach in a supervised by an expert in this, the results are going to be very different. And you’re right, Ozempic face has become very popular in aesthetics, but I didn’t realize that if your protein intake is increased during this, you actually are not going to have that side effect.

It’s the protein intake, it’s the speed of the weight loss, the hydration, the vitamins, all of that part together. But again, there is a certain percent of muscle loss during use with Ozempic, and so you need to balance that out as well.

Do you ever advise people to go on any sort of exercise regimen while they’re getting treated?

Absolutely. I think that, that again is the goal that they’re overall becoming more healthy. Sometimes when people have tried to go to the gym and work out and lose weight through that way and not change their diet habits, they don’t get the weight loss so they feel like exercising isn’t worth it. Again, apart from just speaking from a weight loss standpoint, apart from all the other benefits that we get from exercise. So it’s helping them to see that we have the weight loss here from one side from help with medication through diet, but the exercise is for your health and for toning as well. So we do, I think sometimes patients start in the weight loss and then they start to see that they’re losing weight, they’re starting to feel better, they get motivated, and that’s the point where you can really start to engage them in getting into the gym or an exercise program or something like that. So I would say that in the first couple months, often they might not be there yet, but they start to see the changes and they get excited.

Are people able to engage in effective exercise regimens even though their caloric intake has gone down? Do you find that to be limiting or it doesn’t really matter?

So it’s not that they’re calories are going down. It’s really more about their carbohydrate intake going down. So we want them to still be on a very high protein diet and we also want them to have enough of the good saturated fat as well. Some people who have a high carbohydrate intake in the first few weeks while their body’s getting used to less quick glucose, quick sugar, they may feel a little bit more tired, but as they really are increasing their protein intake, their cells are getting used to less sugar, glucose circulating, they actually start to feel better and have more energy.

Oh, okay. Well that makes sense because one of the common medicinal weight loss myths is that if you’re undergoing that, you’re going to be limited in the amount of exercise, but what you’re describing actually makes a lot of sense.

Because in the past a lot of programs really focused on number of calories. So they looked at saying somebody maybe who is 50 who’s sedentary should only have 900 calories a day or 1,200 calories a day, which is low, and so they were just focusing on number of calories. They weren’t looking at where those calories came from.

Do you often see patients regain weight after stopping semaglutide treatments or if you do, what percentage?

I would say that, that is a concern in initially, when we had patients just go off of Ozempic, just stop it once they hit their goal weight, what happens is because you’ve been suppressing the hormones for hunger, when you stop it, you actually do initially, in the first few weeks have kind of a resurgence or really stimulation of appetite, and so your cravings really go up and so you have to again, counsel people that that’s going to happen because you’re kind of mentally preparing them. In patients that were on Ozempic for a short time, if they then just went off of it cold turkey, then yes, that was happening. And I would say more so in the public that was happening because we kind of took the approach and I understood the fact of the hormone suppression and as we can talk about because of my own use with Ozempic and knowing what happened, then I was able to prepare patients for what would happen.

So we started to do one of two approaches, either weaning them down on Ozempic, so once they hit their goal weight, we stayed on it for maybe a month or still more beyond that goal weight loss just to make sure that their new habits of eating or exercising were in place. And then we started to wean it down. That way it’s not just such a rebound effect and they could kind of test themselves along the way and prepare themselves.

The other way that we started to do things is there’s an oral form of semaglutide, Rybelsus, and so that has been used in weight loss, but they really only saw about an 8% to 10% body mass weight loss with the oral form. But in going from using semaglutide injection, which can have closer to 14%, 15% weight loss, then it’s a good option because it is still inhibiting appetite, not to the same degree, but it’s helping. And so it’s kind of a step-down process as well.

And how long do you keep them on that when you’re doing this sort of weaning?

It really depends on the patient and they have to know themselves. So for myself, I am a vegetarian and I love sweets because my time in medical school residency working, I had horrible eating patterns and I very much crave carbohydrates and sweets. And so for me, I knew that I needed a longer amount of time on the medication because I really needed enough time to change my eating habits in order to make sure that I was effective, because if I did it only for a short amount of time, I would go right back to the same eating patterns that I had before. So it really depends on each person’s circumstance and their love for carbohydrates.

I’m so glad that not only are you on this podcast, but also that you’ve had experience with treating so many patients for weight loss and had your personal experience. So let’s shift over to your personal journey using semaglutide. What made you consider it as an option for yourself?

So when I started reading about it and the studies that were coming out as far as effectiveness for weight loss, and again, I knew that with my lifestyle and amount of stress and my just craving and love of carbohydrates, I knew that I needed something that was going to help me in curbing those cravings. And what I really loved again, was the fact that how you get full faster and if you eat carbohydrates, you’re going to feel very full.

For me, I started to in knowing the two main ways that it works, thought this is perfect for me. That’s when I started and I had always been very thin in my life, and as I neared 40, I started to gain weight and I had never had to follow any particular diet in my life. And so it was very tough because there are people that struggle with their weight from the age of being teenagers and they’ve always struggled, and then there are people that in their forties, fifties start to gain weight and never had to worry about it, and to them it’s kind of a shock and they almost have a little bit of resistance.

For me, I thought, what’s going on? I’m not gaining weight. Something else must be wrong with my body. So when I started the medication, I realized whereas, I used to want to go to the cupboard and get out the chips, and the cookies and everything else, I would go to the cupboard. It was like my mind was telling me, “Okay, we want a snack.” But I didn’t want anything in there. I wasn’t craving anything like that. And so then you have to find other healthy snacks for yourself again to make sure you’re getting enough protein and calories in. But it was really amazing to me to be able to go to the cabinet, see all of these horrible snacks that I had in there and not want to eat them.

What you described is really also a common thing that just talking to friends because I’m obviously, I’m in my forties and that is true. I feel like a lot of us, especially women, when we enter our late thirties to forties, losing weight becomes more challenging as well, and I think we all also probably get busier. Our lifestyles become a little more demising and it’s very common to think, is it my hormones? Do I have a thyroid problem? You’re right. If you are someone who’s always been thin, to suddenly gain weight, you think that there must be something wrong and it must be your hormones. But also in general, I think our metabolism does slow down, but I think also again, our lifestyle, it plays a big part in it. When you decided to go on semaglutide, what were some of the changes that you saw occurring over the course of the months and what were some of the challenges?

The biggest challenge for me was being vegetarian in order to get enough protein in but yet keep my carbohydrate count down. It can be very tough and when I would work in the hospital or just be out, there’s not a lot of readily vegetarian food. They’re much better now, but previously, it was very tough and that’s why you would end up just eating a lot of the carbohydrates, the side of potatoes, the side of whatever they had. And so to me, I had to then start bringing food, preparing food, making sure that I had the snacks there because what happened is that because I didn’t have those options and I didn’t feel like eating mashed potatoes anymore because I just felt full and didn’t have the cravings, that I wasn’t eating, then you start to feel a little weaker. You start to feel… You get dehydrated, and so you really have to make sure that you’re preparing food for yourself or bringing snacks that you have them there so that you are eating healthy. So being a vegetarian is very tough in weight loss and also just that part of hydration because your appetite is decreased, then sometimes that also decreases your desire to hydrate and drink. And so we have to make sure that people are focusing on that so they don’t get dehydrated and feel a lot weaker, faint.

What were some of your go-to protein sources as a vegetarian?

So eggs, often, you could do boiled eggs or egg salad, so eggs were something that were really healthy and helpful. Also, although, lentils have carbohydrates in them, they also have a lot of fiber, so doing different types of different beans or different types of lentils. And then I do tend to have some of the vegetarian foods that they have, even though they are a little bit more processed, but Beyond Meat, they have a good taste and they do have a good amount of protein. So I would do that. Greek yogurt was another thing that I would eat. It has 12 grams of protein in it. I really liked that as well.

I have to agree with you. I became vegetarian recently, I would say six months ago, and I’ve always liked vegetables, but my biggest concern was how to get protein. But yes, it is possible. However, it does require a lot of meal prepping and preparation because I think just in general, the world isn’t there yet where you can readily find protein sources as a vegetarian. There are a lot of vegetarian carbs available, but when it comes to protein, you’re right, you have to do a little bit more prep on your end.

And in looking in the past, with my family, we’ve used some of the programs that send you food to prepare how they have the different meal plans, and they have different ones that are keto, or vegetarian, or a variety of different things that you can choose, but they don’t have a keto-vegetarian one. I’ve looked through multiple different programs and you can’t find a more high-protein that’s vegetarian.

That is a good point because I do see, especially around this time of the year, there are so many food delivery services that have different lifestyle options, but you’re right, I have not seen at least one advertised that shows a keto-vegetarian option.

One last question before we end today. The cost of these programs can be very extensive or at least the cost of being on Ozempic. And I know that some insurances cover it based on BMI or whether you are diabetic or not, but if you don’t meet the criteria for having insurance coverage or semaglutide type drugs, what are some other options?

We try first as much as possible to go through prior authorizations, or appeals, or take the time to do that first. If we can’t do that, there are some patients that will pay out of pocket for these medications, but they are very expensive. They usually just straight out of pocket, $1,100, but if you have certain coupons, might be $900, but that’s a lot of money per month for somebody to do. There are programs, say Canadian Insulin who had the medication initially, they started out at $285 for a vial, but they’re now up to $500 a vial now because as it became more popular then they were raising their prices.

The other option for patients was compounded semaglutide. And that’s been very controversial as far as quality because you really need to make sure that the compounding pharmacy is very reputable, that they’ve done a lot of testing, and so you don’t want to be sent to a compounding pharmacy that really is not top-notch.

And the other issue is of course, that the brands of Ozempic and Mounjaro are really having a backlash against compounded forms of the semaglutide because they don’t want to lose the revenue. So it’s become a concern for people now because they are trying to limit that pathway. And I think that’s very sad because we have a lot of people who benefit from this medication but truly cannot afford the medicine. And initially, when it came out and they talked about Wegovy was the first one that had the approval for weight loss. It was that a BMI over 30 with other comorbidities, high blood pressure, or arthritis of the knees or hips, or high cholesterol, but yet we couldn’t get it passed even though the patients had a couple comorbidities and had a BMI of 35 or sometimes even 40, still the insurances weren’t approving it. That I think was the biggest disappointment.

And the other factor for the compounded forms I would say is I have patients where we actually got the medication approved by insurance, but we couldn’t find it at any pharmacy within a 30-mile radius, and we would try every pharmacy around and they were all out. So that’s another reason I support the compounded forms of semaglutide in a safe compounding pharmacy because again, the supply is just so short and we really are helping so many people through safe use of semaglutide.

I didn’t realize that that shortage is still ongoing and so real and impact so many people who really can benefit.

Dr. Del Pozo, thank you so much for all these insights. I don’t think these are insights that anyone can give without having the level of experience you have with your personal experience and your patients’ experience. And what I’ve learned from this podcast, and I’m sure all listeners have, is that weight loss is very complex and when you are taking a medicinal approach to weight loss, it can really be effective and optimal only if you are being supervised by someone with the experience. And I think that there are so many benefits to it, but again, it requires you to be smart about it and go to a physician who really specializes in it and not be victim to some of the online players and companies who are trying to streamline it and make it a lot cheaper because there’s a lot going on in your body through this journey.And to be successful with it, you really do need to be aligned with the right professional. And with that, if someone wanted to be your patient or wanted to learn more about you, how can they find you?

So they can go to my website it’s eastsacconcierge.com Or calling our phone number, which is (916) 451-2400, and I always do, somebody just wants a free meet and greet to see if this is going to work. We can do that too. But I do video visits, I do in-person visits, and if somebody does live further away and needs to follow up with video or phone calls, we can do that as well.

Excellent. Well, thank you so much. Again, this was very, very helpful. I hope you have a wonderful rest of the year. If we have any other listener questions, I will be sure to send them your way and maybe we can do a follow-up episode with that too.

Sure, I would enjoy that.

Thank you.

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