We Asked a Doctor What to Expect When on GLP-1s

Some people will feel the effects of Ozempic and other GLP-1s immediately, while it may take weeks for others, according to an obesity doctor.

One in eight American adults has taken Ozempic and other drugs that belong to a class of drugs called glucagon-like peptide-1 (GLP-1) receptor agonists. The medications, approved by the Food and Drug Administration for type 2 diabetes and obesity, have been dubbed as miracle weight drugs.

Dr. Alexandra Sowa, a board-certified internal medicine physician who specializes in preventative health, nutrition, and obesity medicine, says GLP-1s for weight loss should be combined with lifestyle changes to achieve a long-lasting effect.

In an interview for Healthnews, Sowa says that before getting the prescription for the drug, it is crucial to understand where weight gain comes from, as it is often a sign of metabolic dysfunction affecting 88% of Americans.

Q: What makes you the right candidate for GLP-1s for weight loss?

A: The FDA has very clear regulations for prescribing these medications. Generally, they're prescribed for people with a body mass index (BMI) greater than 27 and comorbidities like high blood pressure, insulin resistance, sleep apnea, and joint pain.

However, BMI is an inexact screening tool, so there can be times when it does not qualify you for these medications. We might also look at body fat measured by waist-to-hip ratio.

The really important question is, will insurance cover it? Unfortunately, it seems that insurance companies are making up their own guidelines to cover fewer and fewer people.

Q: Speaking of body fat, is there a specific percentage that qualifies patients for GLP-1s?

A: Generally, a body fat percentage of over 30% for women and over 25% for men might put you in the obesity category.

It is not the most commonly cited tool, but we're starting to explore it within the obesity medicine community and the endocrine societies. We know that the goal of this is not for skinny and vanity; it's for health.

Sometimes, people don't fit into this pretty box of BMI metrics, so we might miss people with significantly excess body weight. If we're not screening for it, they are left in the dust.

Q: Do you need to see a health provider in person to get a prescription for GLP-1s, or is a telehealth visit enough?

A: I myself converted my medical practice from a brick-and-mortar to a telehealth practice even before the pandemic. Because I realized that consistent levels of support in using these medications were more important than coming in.

It's hard to step away from the office or life for three hours to get to a 20-30 minute doctor's appointment. That's why telehealth has really taken over with that set.

It is very important to work with a specialist who understands these medications, uses them ethically and responsibly, and supports people holistically.

Not all telehealth or online programs are created equal. I also think that there's still immense value in seeing a doctor in person who knows you and can perform a physical exam.

In instances like that, many doctors will use body fat composition scales and be able to do assessments that are a little different from what you can do at home. However, telehealth for each of these medications is safe when you work in conjunction with a local primary care provider who could see you in person if needed.

Q: What can patients expect after initiating GLP-1s? How soon will they start experiencing the effects of the drug or side effects?

A: With GLP-1s, there is a long titration schedule, meaning that every month, a patient can go up on the medications. That helps us get to therapeutic dosages.

While some people will experience the effect of the medication after the first dose, for many, it takes many weeks to build up in their system.

Generally, the medications' effect on hunger, food intake, and side effects is most significant in the first 24 to 72 hours after the weekly injection and naturally wanes a bit by the time you need to take your next shot.

Often, people will time their dosage around that. For example, knowing that the weekends are the hardest for them to control how they eat, they will take the drug ahead of the weekend.

Side effects are very common on these medications. In my clinical experience, almost everybody experiences something. According to population studies, 50% of users routinely experience constipation, nausea, or diarrhea.

But it doesn't happen every day. For some people, it's enough to make them stop the medication. However, it often has to do with not eating the right things or being on too high of a dose.

When it comes to my patients, we don't always take them up to the next indicated month's dose. We go by how they're doing, how they're feeling, and their rate of weight loss. That's one way to help people minimize these side effects.

Q: What side effects require seeking medical help?

A: We often hear about side effects from these medications, and even I just referred to them as side effects, but they aren't really negative and do not necessarily need medical care. They're not adverse effects, just byproducts of how the medication works.

The drugs work by making your brain to be less hungry, rerouting chemical pathways, and decreasing stomach emptying time. They also decrease transit through the gastrointestinal tract. By proxy of how that works, some of these side effects happen naturally.

Adverse events might happen if you are unable to tolerate taking in any food or drink. If you're vomiting and can't stop and can't drink water, it's time to seek care. If you're feeling constantly unwell on the medication, you have to talk to your doctor.

Any constant or even fleeting pain in your abdominal area is not normal. It can be a sign of gallstones, which are not caused by the medication but are secondary to weight loss.

Reflux is another common side effect of decreased stomach emptying time, and medications can help with it. People may also need to reroute or rewire some of their food habits and maybe focus on eating slightly less because overeating can trigger reflux.

Q: What is the role of diet and exercise in weight loss on GLP-1s? Do you have to engage in a specific type of exercise or follow a particular diet?

A: These medications are not a magic wand. For some, it can be life-changing, and it alters your brain in a way that feels like magic.

But we still have to do the fundamental work of health because the goal is not just to lose weight but to reestablish metabolic health within the body.

These medications have been accused of making people lose muscle, but that's not the truth. When you lose weight, you lose both fat and muscle, and we care about the ratio.

The findings of the studies are mixed. With semaglutide, the muscle-to-fat ratio loss is just a little bit worse than it is with traditional dieting. However, with tirzepatide, the ratio is significantly improved compared to traditional dieting alone.

Specific diet and exercise are important because we want to preserve and build as much muscle mass as possible during weight loss. I always tell my patients that two ways to do this are to eat protein and to make protein. Weight training is very important in this journey, as is prioritizing protein at every meal.

I'm also a huge fan of having people use this reset with the medication to reprioritize the relationship with food.

Some people who have only gravitated toward hyper-palatable packaged foods will say that they have more time and space in their brains to think about how they want to assemble their meals and will prioritize whole foods and less processed diets.

Some people might need lower carbohydrate intake to fix significant metabolic dysfunction at the start.

But for most people, if they prioritize protein, make sure they're getting vegetables in, and have an appropriate amount of fruits, they can enjoy the other foods that might have felt totally off limits.

Q: Can building this lifestyle of eating healthier and exercising more prevent the return of weight after discontinuing GLP-1s?

A: I would like to start this answer by asking if we think about the need to stop medications immediately for the treatment of any other disease.

If someone needs medication for thyroid disease, are we focused on when they get to stop Synthroid? Or if someone has uncontrolled blood pressure that's not managed through lifestyle alone, do they go off the medicine when they achieve their blood pressure goal?

Unfortunately, weight carries such biases and stigma that people are focused on when they get to come off the medication.

The studies show that when we stop this medication, up to and beyond 75% of people will begin to regain weight.

Weight cycling is very unhealthy for the human body. Regaining weight is mentally devastating and disrupts basal metabolic rate. We'll often end up with a lower basal metabolic rate than our starting highest weight.

Building muscle, fundamentally changing food habits, prioritizing protein, giving our brain a break from constantly thinking that we'll fail at this, and rewiring our thoughts of our relationship with our body and our food can lead to being able to titrate down and potentially go off of the medications.

But there's nobody who can go on this medication, not change anything about their life, and expect to go off medication and maintain that weight loss.

Q: Many people don't have access to these drugs, primarily due to the cost, but want to lose weight. What would be your advice to them?

A: The government needs to start getting involved. Medicare is now covering Wegovy, which is remarkable because it has been banned from covering any weight loss drugs.

Wegovy is covered in the specific instance of reducing cardiovascular risks in patients with heart disease and obesity.

I hope that in the future, we will be able to gain access through government relationships and pharmaceutical companies, making this drug much more affordable.

GLP-1 medications aren't the only drugs on the block. Qsymia and Contrave are approved for long-term use to manage obesity. The number of people having significant success on these medications is lower than on GLP-1s, but it doesn't mean they won't work.

These medications and their individual components can be written generically, so it's worth seeing an obesity medicine specialist who understands these medications.

The first generic of GLP-1 liraglutide for weight loss has just entered the market.

However, we need to understand that weight is generally a symptom of metabolic dysfunction. Eighty-eight percent of Americans are metabolically unhealthy. If we look at labs — glucose, insulin, hemoglobin A1C, lipids, and triglyceride — we'll find that people have some metabolic dysfunction leading to weight gain.

That person comes in and says: I'm doing everything right, and I'm still gaining weight.

Generally, that person will have something in the body saying that they are dysregulated in taking food and storing it as fat.

Weight gain often comes from things like sleep apnea, the treatment of which may be covered by insurance.

The solution shouldn't just be to eat less and exercise more but to ask why we gained in the first place.