News about weight-loss drugs is hard to miss. A new generation of drugs — Ozempic, Wegovy, Mounjaro, Zepbound — are on television, on billboards, and in many of our homes. There is little debate about the efficacy of the drugs for weight loss (they work, at least for most people) but lots of discussion about everything else surrounding them.
What I’ve found missing from this conversation is the answer to the practical questions I think many people would like to ask their doctors. Are these drugs right for me? How do the side effects work? How fast would I lose weight? Do I really have to take them forever? What if I’m breastfeeding?
Today I brought on Dr. Gillian Goddard to talk about this. She’s an endocrinologist in private practice, and she writes our Hot Flash newsletter (sign up on your Account page!), all about the post-reproductive years. Gillian has been prescribing these drugs for many years, and she’s extremely thoughtful about who is a good candidate and who isn’t. I learned a lot here, as I always do from Gillian, and I’m sure you will too.
Here are three highlights from the conversation:
How are the effects of these weight-loss drugs different from what was offered in the past?
The kind of weight loss we see with this class of medicines is more akin to the weight loss people see with bariatric surgery than it is to the weight loss that people saw in the past with older weight-loss medications. So they really are paradigm-shifting. Why? There’s a lot of reasons why. For one thing, we’re really starting to understand that a lot of what gets in people’s way as far as losing weight is not appetite. It’s not appetite, and it’s not what they’re eating; it’s how their body is processing what they’re eating. If somebody’s not processing carbohydrates well and that’s impacting how they’re storing carbohydrates and we can change how they’re processing carbohydrates so that they’re processing them more typically, then all of a sudden, we can have a big impact.
The other thing that we’re really starting to understand is that GLP-1 [the drug] and the hormone insulin actually have effects in the brain around satiety, around the reward system, and around metabolic rate. All these things are really closely linked, and so when you give someone GLP-1, you raise their GLP-1 levels in their brain and you decrease the insulin levels in their brain, and that will have big impacts on things like “food noise” and the reward people feel from consuming something super-salty and crunchy or sugary.
Who is a good candidate for these drugs?
I look much more holistically at a patient who’s coming in to see me. I want to know what their blood sugar levels look like, what their insulin levels look like. Are they having blood pressure problems? Are they on cholesterol medication? Are they having problems with mobility because of weight?
I really care much more about how weight is impacting someone’s broader health when I think about these medications, because there’s data that shows that just having a high BMI in and of itself is not the problem. The problem is when the weight is associated with other medical problems. And that’s where I like to focus my efforts and goals too.
How do drugs like Ozempic impact pregnancy and fertility?
The issue is really around intake, and I think especially most American women, we’re usually pretty well nourished going into pregnancy. We have some reserve that a couple of weeks is not going to have a huge impact on the health of a baby. The mice studies, obviously they had the mice on the drug through the whole time, not for a tiny fraction of the pregnancy. So I definitely would not panic. There are a few case reports out there at this point of people who maybe didn’t know they were pregnant until late first trimester or early second trimester, and those case reports don’t show any significant issues.
The other factor is with tirzepatide specifically, so that’s Mounjaro and Zepbound. This has not necessarily been shown to be true of the other medications, like Ozempic and Wegovy. But with tirzepatide specifically, they have shown that with certain low-dose birth control pills, the way the medication affects how the birth control pill moves through your GI tract can delay its absorption. If that’s the case and you’re not super-careful about taking your birth control pill regularly, you could have enough of a drop in the levels of the hormones in the birth control pill that would allow you to ovulate and then that would obviously allow you to get pregnant. The key there is really taking — and you should do this all the time anyway — but taking your birth control pill at the exact same time every single day. It may be helpful in this case to take it on an empty stomach and, if you’re really worried, to use a different method of contraception.
Full transcript
This transcript was automatically generated and may contain small errors.
We often use Ozempic as a shorthand for a broader class of GLP-1 drugs. They’re also called semaglutide, but you may have heard of Wegovy, Manjaro, Rybelsus, Zepbound. Broadly, these all do roughly the same thing, which is that they treat type-two diabetes and they help people lose weight. So much of the discussion in popular culture about this is about these big picture social questions around these drugs. What are the societal implications of all of these drugs becoming available and helping so many people lose so much weight? How does this change our relationship to the food system? How does this change the stock market price for Nabisco? How should we think about body positivity and the way we think about weight, and how that relates to these new options for weight loss?
But today I wanted to talk about a narrower question, and one I think many people ask, which is, are these drugs right for me? And so I invited an endocrinologist to address this smaller picture. You might remember Doctor Gillian Goddard from the episode on perimenopause and birth control later in life. She writes our newsletter, Hot Flash, which you should be subscribed to immediately, I love it. And today she and I are going to talk about GLP-1 drugs. We’re going to talk about how she prescribes them as an endocrinologist, about who is a good candidate for these, and about how the findings from trials do and do not translate into the way she uses these drugs in her patients.
I was interested to ask her, how do you get people on the drugs? What kind of side effects do they experience? Do they come off the drugs? Do you find that people have to take these forever? I’m hoping that this conversation will be the path to a conversation that you could have with your doctor, if this is something that feels right for you. If you’re curious about the drugs yourself, or just generally interested in what feels like an inescapable phenomenon, this is the episode for everything you want to know about Ozempic, but have no one to ask it to.
And before we get going, I want to be clear: these drugs are not for everyone. Plenty of people have no interest in them at all, and we’re certainly not here to talk anyone into anything. But the drugs are here, probably to stay, and I think it is important to understand how they work.
After the break, our own doctor, Gillian Goddard.
Many of those articles are either about a new study which says Ozempic also fixes this problem that a lot of people have, or it is a big picture question about how society is going to change with the result of Ozempic. And some of these are quite interesting as an economist. So, people are talking about are we headed for a collapse of the snack food market and should you short Doritos in the stock market or go long Peloton or whatever it is, short Peloton. I don’t know. Economics is complicated, but the conversation I want to have today is about being a doctor, treating Ozempic on a much lower level because that’s something that you do a lot. Correct?
What’s different is how effective these medicines are and how frequently they have to be given. The very first GLP-1 exenatide was a twice daily injection and that was difficult to get even type two diabetics to do. Semaglutide and tirzepatide, so semaglutide again is Ozempic and Wegovy. Tirzepatide is Mounjaro and Zepboud. Those medicines are once weekly medicines.
The kind of weight loss we see with this class of medicines is more akin to the weight loss people see with bariatric surgery than it is to the weight loss that people saw in the past with older weight loss medications. So, they really are paradigm shifting. Why? There’s a lot of reasons why. For one thing, we’re really starting to understand that a lot of what gets in people’s way as far as losing weight is not appetite. It’s not appetite and it’s not what they’re eating, it’s how their body is processing what they’re eating. If somebody’s not processing carbohydrates well and that’s impacting how they’re storing carbohydrates and we can change how they’re processing carbohydrates so that they’re processing them more typically, then all of a sudden, we can have a big impact.
The other thing that we’re really starting to understand is that GLP-1, the hormone and insulin actually have effects in the brain around satiety, around the reward system and around metabolic rate. All these things are really closely linked, and so when you give someone GLP-1, you raise their GLP-1 levels in their brain and you decrease the insulin levels in their brain and that will have big impacts on things like food noise and the reward people feel from consuming something super salty and crunchy or sugary.
I really care much more about how weight is impacting someone’s broader health when I think about these medications, because there’s data that shows that just having a high BMI in and of itself is not the problem. The problem is when the weight is associated with other medical problems. And that’s where I like to focus my efforts and goals too.
My goal is one to two pounds a week on average and I have them stay on a dose that gets them a rate of weight loss in that range until it stops working. So, many of my patients will stay on much lower doses. And my goal with that is twofold. One is I think that’s a much more sustainable rate of loss. I think it’s easier to minimize muscle loss when people are not losing weight so rapidly. It also minimizes side effects. So, the other thing you will hear a lot about with these medications is people saying that they are throwing up all the time. They’re super, super sick. I always tell my patients, you should never be throwing up. You may be nauseated at times, especially within the first 48 hours of taking the dose, but you should never be throwing it up. And if you’re throwing up, I want you to call me and let me know because that means we need to make a change. So, a more gentle upward titration can allow us to balance the benefit with some of the side effects of these medications.
Can we briefly talk about logistics in terms of is it possible to get this and how much does it cost? Because I think both of those have been barriers people have talked about.
So, it used to be back in the old days, like five years ago, that if somebody had pre-diabetes or signs of insulin resistance, some insurance companies would cover the diabetes medicine for patients who did not meet the criteria for diagnosing diabetes, but those days are over. If you have anti-obesity medication coverage, the coverage is typically quite generous. I have a lot of patients whose copays are in the neighborhood of $25 a month. The list price for these medicines is 11 to $1,300 a month. Obviously, that’s quite generous coverage. Both companies have pretty generous coupon offers that knock down the price by about 50%. Then you’re looking at something closer to 500 to $600 a month. Prohibitive for many people, no doubt, but better than $1,100 a month. The challenge is that I’ve had patients switch insurance, they get a new job and they go to their new job and their old job had coverage for anti-obesity medications and their new job doesn’t, and we’re left scrambling to think through how to manage that.
The other one that people complain about a lot is hair loss. That is also just a side effect of rapid weight loss. It is evolutionary. There’s not a lot to do about it other than to make sure that you vitamin replete as you’re losing weight so that you can grow new hair back. But all of the side effects that people talk about specific to these medicines like Ozempic face and muscle loss are all things that would happen if you had the same degree of weight loss regardless of how you did it.
That has not been my experience. There are no studies that say this is the method you should use to take people off the medication. I have titrated people off and down on these medications. In a few cases, people were having such a good response to the medicine that we were like, oh, whoa, whoa, whoa, hold on. We got to go down quickly because you’re losing too much weight. But most people, it’s a really gentle downward titration, similar to the titration we do to put people on these medicines. The people who do the best coming off of them I find are the people who their lifestyle was not the issue to begin with. I mostly see women in my practice. I would say my practice is 90% women. So, these are mostly women often who have issues like polycystic ovarian syndrome where they have struggled with weight for their whole lives, their diets were dialed in and they were exercising, so they really didn’t make a lot of changes when they went on the medications.
They’ve achieved their goal weight as they’re titrating off the medication. They’re just continuing the same lifestyle that they already had when they started the medications to begin with. Those people tend to do really well. Some people prefer to stay on a small dose, and I have had patients who do things like stay on the smallest dose or they stay on the second-smallest dose, but they take it every 10 days or they take it every two weeks just to titrate themselves to stay in their goal range without taking the medicine on a weekly basis. But I’ve also had patients come off. I’ve had patients come off and be on no medication. I’ve had some patients come off and choose to be on a small dose of something like metformin, which can help with weight maintenance and decrease your risk of developing type two diabetes. Many of these patients are at risk of developing type two diabetes because of their biochemistry and their genetics. So, there’s lots of different ways to do this and I approach each patient differently.
The authors also point out that what they showed was not a causal relationship. It was an association. And they themselves said that they didn’t know what a possible mechanism for this would be, that they couldn’t show that there was a dose relationship, and they couldn’t show that if patients stopped semaglutide, whether or not this would get better or not. And those are all key things, key components to showing that a relationship between a medication and a symptom are causal. You really cannot say that semaglutide causes this type of optic neuropathy, but rather there may be an association. Before we get excited about this at all, we need a lot more research into this. And it would not stop me from prescribing these medications to people.
Also, remember not taking these medications or stopping them can lead to other much more common diseases like heart disease, high blood pressure, diabetes. Those diseases are super common and make people sick every single day. And so in my mind, the benefits of semaglutide still far outweigh the risks of this particular type of optic neuropathy.
The issue is really around intake and I think especially most American women, we’re usually pretty well nourished going into pregnancy. We have some reserve that a couple of weeks is not going to have a huge impact on the health of a baby. The mice studies, obviously they had the mice on the drug through-
The exposure that the baby has to the drug is vanishingly small. And in fact, some of the databases that talk about the safety of medications and breastfeeding say that semaglutide is probably safe in breastfeeding for all of those reasons. If breastfeeding is really a goal of yours and is really important to you, the bigger issue is actually the impact that the change in nutrition and the change in hydration may have on breast milk supply. So, I do always warn people about that because some women’s bodies and breast milk supply will be more sensitive to changes in calorie intake than others. So, I don’t want somebody to be disappointed because they decided to go on one of these medicines and it tanked their supply. I’m more worried about that. I do think as babies get bigger and more resilient, it’s also a little easier to think about these things as well. Maybe you don’t want to go on semaglutide the week you come home from the hospital-
ParentData is produced by Tamar Avishai, with support from the ParentData team and PRX. If you have thoughts on this episode, please join the conversation on my Instagram, @profemilyoster. And if you want to support the show, become a subscriber to the ParentData newsletter at parentdata.org, where I write weekly posts on everything to do with parents and data to help you make better, more informed parenting decisions.
For example, Gillian has actually written out a lot of what she talked about today in an article titled, appropriately, “Ozempic, Mounjaro, Wegovy, Oh My! (yes, with the exclamation point), that dives even more into the numbers, and which you can read at parentdata.org.
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