GLP-1s & Weight Loss
What types of GLP ones are there and how do they work?
That’s a great question. First, let’s discuss and make sure we know what exactly are GLP-1s. GLP chemicals are glucagon like peptides. These were originally approved by the FDA all the way back in 2005. These were mostly research drugs initially. There was significant caution when they were developed before letting it/them out into the open market. By themselves, these drugs don’t really treat weight loss or obesity single-handedly. They were not really designed for that. They were designed to help with diabetic patients or diabetes management. It’s understood now that these drugs are most effective in combination with other efforts, specifically diet and lifestyle changes. The best effects/results are seen when the patients do their best under the watchful eye of their practitioner, working towards a defined goal.
I have heard there are lots of “issues?” What are they?
That’s a very good question. Most patients have good results. However, many of them are plagued by issues like nausea, constipation, diarrhea and vomiting. That’s not in all cases. Some patients have other issues like fatigue and headaches. I have seen all of these problems in patients. Unfortunately, it’s very hard to tell you which patients will have which difficulties, if any—some have no problems. Also, the medications tend to be very specific and customized. I will explain. I’ve seen difficulties and complications with Ozempic, Wegovy, as well as Mounjaro. Between all of these and others like Zip-Bound, I have seen the least number of complications/problems with Mounjaro. That, however, is one person‘s experience (mine) and so is anecdotal. I am sure that other physicians may have different experiences. The point here is that you should be aware that there are possible complications but that they are manageable in most if not all cases.
Am I a better candidate for one drug versus another?
That’s a very fair question. As I noted above, the drugs tend to be very particular/specific. For this reason, the only way to really know which drug/medication works for you is to try a few. Ironically, because insurance companies tend to have contracts with one company or another, that may not be possible. Thankfully, as we have learned, there may be generics coming down the pipeline. If so, the cost may be much less problematic in the future. As these generics become available, you the patient may have many more choices soon. That being said, I would simply approach your primary care doctor and see what is in your care plan and start there. If in fact, you do not have that option, I would simply start with a drug like Mounjaro and see how it goes. Again, as I mentioned, the cost profile in some cases may be prohibitive. This may ultimately push or guide your decision.
Do you do GLP’s in your office?
Actually, we used to. I suspect in the next year or so, we again will start carrying GLP-1s. It is a part of the overall profile of managing someone’s care with massive weight loss. I would love to be able to not only manage the initial medications, but to also be able to nutritionally manage a patient all the way through their journey. At this point in time, however, I/we tend to work with multiple internal medicine offices that actually do the injections and weekly monitor the patients. We have chosen to separate our tasks and our responsibilities—We take care of the surgery–They take care of the medications.
I have heard that they’re going to be some generic forms of these drugs. Is that true?
That is absolutely true! We have also heard through the FDA that the generics are being developed. The generics will more than likely have comparable chemical profiles and similar types of complications as I mentioned earlier. Thankfully, none of these are life-threatening. Like before, you simply have to try them out. Because they will be a lot more cost friendly, we suspect more and more patients will have the opportunity to afford them and hopefully will benefit from this new development.
I have lost a tremendous amount of weight. When will I plateau?
That’s actually a very good question and one that is important to discuss. We cannot really predict how people respond to these medications. I have seen patients take the medication diligently and lose minimum amounts of weight. I have seen other patients take the medications and have their weights literally drop like a rock. Based on this variable response, we simply wish to make sure that you as the patient are in a comfortable position before we actually talk about the next step(s). We need to not only look at the scale but make sure that you too are ready. We/you need to decide what you think is a good stable weight for you. This is a conversation to be had as a member of a team. You, the patient, the medical team managing you and we, the surgeons should all be involved. Ultimately, you will be the one to make the decision. However, our job is to make sure that the decision is made with the best information available. Again, this is done on a case-by-case scenario. Thankfully, and hopefully this is a decision that we can help you get to with confidence.
I have already lost my weight. When will I be ready for surgery?
That’s another great question. As I mentioned in the question before, it really depends from patient to patient. Once we feel that your weight has stabilized and you’re no longer losing any significant weight over the next few months, then we start thinking that you have plateaued. Previously, when we completed gastric bypass surgery or gastric sleeve surgery, we routinely waited for a year for the weight to stabilize. The same caveat applies here. Once the weight loss has stabilized, and there’s only a few pounds of loss here and there, then we start thinking that the weight has in fact stabilized and we proceed with surgical planning. Again, as I mentioned, this is a team effort. This is something that has to be looked at, discussed and planned with you as the focus but with additional information from both the surgery team and the medical team–We have found that a team approach always seems to give the best results.
What types of surgeries/procedures are there? Which one should I do?
That really depends on you. There are many operations we can do. However, like being in a store and having multiple options, YOU ultimately have to make the choice. After massive weight loss, usually the tissues tend to hollow out. There are multiple areas that we focus on in regard to surgical intervention(s) or procedures. This includes the neck and face. The procedures here would be a neck lift or a facelift. In some patients, the upper body seems to need the most help. This would be the upper trunk which involves the breasts, as well as the arms. Here we could put in implants or simply do a breast lift. As for the arms, a brachioplasty is done to get rid of the “bat wings “(not my words—this is what the patients call them). In some other patients, there is excess skin on the back around the bra lines. Here we would focus on an upper back lift to get rid of this excess skin and hide the scar under the bra line. Some others focus more on their lower body. A traditional abdominoplasty or a modification that goes all the way around (360-circumferential lipectomy) can be offered and performed. Along with this lower body procedure, we tend to do a butt lift and/or a medial thigh lift to address the excess/extra skin in the legs and to make them more shapely and pleasing. Again, these operations can be done in combinations as needed or separately. There is no need to push you or to rush into these operations. Ultimately, you as the patient going through the journey have to decide. Our role as the surgery team is to educate you on the operations, the choices as well as the possible complications. Our role here is to guide you through this journey as safely as possible.
Are there possible complications from the surgery?
Of course there are. Like any operation, there are complications. These include things like blood clots, infections, scarring, fluid collections (seromas) and skin breakdowns. The list of complications can go on and on. However, in our experience, we have learned that a good pre-operative planning can minimize the number and the possibility of complications. This of course is in the setting of a healthy patient who has made appropriate lifestyle and dietary changes. Also, in many cases, we have nutritional support and involvement to make sure that you as the patient are healthy and the best pre-operative candidate possible. One of our mottos is rather simple—If you go in healthy, you will come out healthy. AND your recovery will be more than likely shorter and less problematic.
What things can I do to get ready for surgery?
That all depends on what type of procedure we intend to do. For example, in some of the larger surgeries/procedures, protein levels and nutrition are essential. We would like to make sure that all the vitamins that you are getting are maximized before surgery. This ensures your healing factors are the best. This includes things like Vitamin B12 and Vitamin A. In some cases, Vitamin B 12 is not absorbed well. This then impacts your blood cells and your bone marrow. In these patients, B12 shots are advocated. However, again, this is not something that we would randomly or routinely do. We would like to look and evaluate each patient separately. For that same reason, the pre-operative, the operative and the post-operative plans will be unique and need to be customized to what you are and what you need. There is no routine answer to this question.
Is nutrition important? Before or after?
As I mentioned earlier, this is a very important question. The answer is just as important. Nutrition, especially in patients that have gone through modifications with GLP-1s is critically important both before and after surgery. If in fact, we notice any type of deficiency before surgery, we wish to optimize and correct this before surgery. There is no point to rush the surgery if you’re not ready. That would be a mistake. Our job is to get you to surgery in the healthiest condition possible so we can ensure that you come out of surgery quickly and in the best state possible. This is routine. However, you would be surprised how often it is missed. Things like B12 shots as we mentioned earlier, help heal patients. Other vitamins also help. Other supplements like Vitamin A and iron pills also help greatly. Again, not every answer is correct for every patient. We need to custom tailor the intervention and the planning to each patient. Your journey is unique to you. Our job is to make sure that it is smooth and uneventful.
Will insurance pay for any of my surgeries or procedures.?
Unfortunately, as it is now, most of the post massive weight loss procedures are not covered by insurance plans. I suspect that in the next few decades, some of these may be covered. As of this point, however, they are not. That being said, we are happy to offer whatever means possible to make these surgeries and procedures achievable. This includes financing and/or additional planning. Again, our job is to walk with you through this journey. We will do our best to help you achieve your new you.