What about these new medicines? You may not recall, but I’m actually the past president of the Obesity Medicine Association. The Obesity Medicine Association (OMA) is the largest group of medical weight loss doctors in the world. I think there are 4,000 doctors now who treat obesity as a specialty. The training involves in-person classes at meetings and then also online training; you actually sit for an exam called the Obesity Medicine Diploma. What I’m trying to lead up to is that you should get special training in order to use these medicines safely. We’ve created a way for you to learn and then get certified in obesity medicine. I say “we” because this goes back 10-15 years when we were actually creating this pathway for certification, and I was part of that pathway. Most obesity medicine doctors in the U.S use medications. They don’t use the prescription strength keto diet like I do; most of them don’t. I’ve been teaching the prescription strength keto diet path at the Obesity Medicine Association meetings for over 10 years now.
Weight-loss medicines
There are a lot of other doctors who are starting to use it, but this is the minority. Most doctors who are in the obesity medicine world use medications. Best tip: the medicine is paired with a diet that is either low calorie or low carbohydrate; the medicines work better that way. What’s interesting is the time-honored medicine among this group was called Phentermine. It may ring a bell if you’ve been in this area for a while with Fen-Phen. It’s not Fen-Phen. You may remember in the 1990s, Fen-Phen came out and was extremely popular and then went away because of some concerns about heart risk. Phentermine is the most common medicine used.
It was interesting because when I was president of the OMA Society, a couple of companies were starting to make new drugs in the obesity world. Because for a long time, and for 50 years now, there was only Phentermine, which still works today. It’s still very commonly used. But among other companies, Novo Nordisk started making medicine to target obesity. I remember sitting in a meeting where the people from the company came and gave the presentation to the board of our organization of how they have this research and development going on to make new medicines for obesity treatment. Being president of this organization, of course, I was excited, and I am excited. I think there are so many complicated factors and nuances and carb addiction and sugar addiction that we need many different tools to help people. Just to tell you, I’m not morally opposed to using medications. In fact, I think it’s a good thing that in many doctors’ minds – especially those who go through the obesity medicine training – that obesity is not unworthy of medicine treatment. That was the old way that doctors thought about it or even you might think about it. It may seem strange coming from me, known as a weight loss lifestyle guy, that medicines can be helpful. It’s not a long-term proposition, but it might be something to use to get you to your goal. Somebody is going to have to teach you – or you’re going to have to teach yourself – how to maintain the weight here while you’re at the goal.
The tragedy of medications and surgical weight loss is that they can often get you to the goal, but then either you forget to go back, or you’re not welcomed back, to the Surgical Clinic because they don’t really know how to do anything other than do surgery so that you don’t learn how to keep the weight off. You just go back to the way you were eating. And sadly, many, many people even with weight loss surgery or medicines will go back to where they were because nobody taught them how to keep the weight off. That’s what we want to do for you – get you to the goal and then help you keep the weight off. The best lifestyle treatment that I know of is one that’s super low in carbs, now called keto, and doing it in a properly formulated way. You focus on protein coming first. You don’t add in fats and oils and all that.
The news came out that people like Kim Kardashian and these stars were using Ozempic, which is a drug that is approved in a different form for weight loss. These medicines can help, but you still have to have that adding on of teaching or training on weight loss of eating and maintenance. My preference is to use lifestyle as the way to get you to the goal and then to maintain it because then you’ve learned how to lose weight and keep it off all at the same time. The allure of something like Ozempic or other weight loss medicine is that you really don’t have to focus much on changing the food while you’re losing weight. What happens with these new injectable medicines is that you get a pen with a small needle and you inject the drug once a day or once a week, and it cuts your hunger out, sometimes even to the point where you don’t eat anything. That’s very good for weight loss. In fact, the fastest weight loss method is total fasting – not eating anything! The problem is, it’s not the healthiest way to do it. I want to help you lose weight and keep it off in the healthiest manner possible, which again, still for me, is lifestyle change, changing the diet.
There are a lot of people who just can’t wrap their heads around changing the food. It could be that it’s just hard to teach them or they’re not really interested in changing anything. So now the doctor is in the position where we could give you just a shot, just a little injection pen, and everything’s done for you. Your hunger goes down, you eat less. The allure of using it is that it’s very effective and it’s very easy to use, and the person you’re dealing with doesn’t have to think about much. They don’t have to learn a new way of looking at food, and you don’t have to teach them all this. Unfortunately, we’re in a space now, which is very common in this world in the U.S., where the marketing is out there, the stars are out there using this, but for the average person, it’s too expensive. It’s $1,000 a month in order to get the medicine if it’s not covered by your insurance. To Kim Kardashian or whoever was popularized using it, that’s nothing. They clearly have the money to spend on that. If it’s covered by insurance, then the cost is much less. I’ve even heard now that some doctors are able to get it off-label to keep the cost down. Let’s say it was free, and you could just go get it. It’s covered by insurance, and it’s a $30 or $50 co-pay each month. That might be something you’d want to consider, but I wouldn’t just do it without learning about proper nutrition.
The damaging side of weight-loss drugs
Here’s where I think some people will be hurt or will be given a treatment that doesn’t allow for optimal healthy weight loss. What’s happening now is that any doctor can prescribe this medicine. They’re not trained in nutrition. I’ve pretty much confirmed just about any doctor trained in the last 30-40 years in the U.S. has received no nutrition training. You can assume that. They learn about nutrition from TV, like you do. So now doctors will be prescribing left and right. There are some people who don’t eat at all over a several months period, and their weight loss is similar to surgical weight loss because surgical weight loss is caused by having people not eat anything or having very little. The damage done, we know from surgical weight loss, is that you lose muscle mass. If you don’t eat enough protein after surgery, you will probably lose some lean body mass, and that’s not what you want as far as the healthiest way to lose weight.
With these medicines, you don’t have to teach people much. They just get the drug and use it. It may or may not be expensive depending on your insurance, and then the side effects are tolerated. When I first saw Saxenda – the weight loss version of this medicine – about a third of people had nausea, but it was tolerated. It goes away after a couple of days. You’re buying into the fact that you’re going to be on the tilt-a-whirl or on a spinny ride for a day or two. You adopt the side effects that these medicines will give you, and yet it’s still maybe worth it if that result is really what you want. That is, rapid weight loss from not eating.
I want you to eat!
I want you to eat something every day. The protein section of the food list is where you should eat if your appetite is so suppressed. Have some meat, poultry, fish, shellfish, and eggs, then I know that you’re going to get some protein that day. I have mixed feelings about the need for new treatments because some people who come to me won’t, for whatever reason, wrap their head around doing the program like this. I still think they’re deserving of some kind of treatment. You may actually be in the old way of thinking where you don’t want to take a drug for this. Obesity is such a complicated thing that it is a disease worth treating with medication; it may be something pretty easy to consider. I don’t see it as a first-line thing to try if the lifestyle change is effective and it clicks with you then you don’t even need the medicines.
What weight-loss doctors have on offer
As obesity medicine doctors, we have prescription strength diets, which is what I start with. We have prescription drugs – pills and shots, and then there are programs you can also purchase from the doctors called very low-calorie diets. Those are shakes and bar programs you purchase from the doctor. You get medical supervision and if you stick to these products you will lose weight because the calories are brought down to about 600-800 per day. It’s a very low-calorie diet. There are more side effects including fatigue and hair loss, but it’s a potent, powerful way to do it. These are the things we have as medical weight loss doctors, all of which are less risky and have fewer side effects than surgical weight loss. We are not surgeons. We have a different philosophy.
Dr. Vera Tarman says that we’re living in a “processed food sugar environment,” which is a disaster, like a blizzard. It’s hard to avoid all this stuff. Our philosophy as medical weight loss doctors is, we either teach you to avoid it, which is like a keto diet, or we give you medicines to make you eat less of it. Surgeons have the philosophy of, “Well, we’ll just lop out a part of your stomach in order to live in this environment of a blizzard.” The ultimate fix for all of this is stopping the blizzard of sugar and highly processed foods into our environment, in our world. But that’s going to take a long time – or it may never happen.
Audience questions/comments
Comment: “I was appalled. Our local weight loss clinic is offering weight loss surgery and injectable meds to a friend who is active and able to play Pickleball four days a week and run around with her grandkids. She was just unhappy she is not losing weight. I’m trying to get her to try Keto Made Simple.”
Answer: It’s not unusual in our area here in North Carolina. Even the other doctors refer people to surgery and they don’t think of medical weight loss. They don’t think of just changing the food. The surgeons have done a great job at marketing themselves and getting themselves in front of all these other doctors. I would certainly think that your friend should try medical weight loss – which is the prescription-strength diets and prescription-strength drugs – before surgery.
Comment: “I have an overweight twin sister, a retired nurse who is married to the Weight Watchers method, and I haven’t found the key to opening up her mind to challenging her current thinking.”
Answer: Well, is she successful with Weight Watchers? If not, that’s the problem. Weight Watchers was developed when we were using phones with cords and flip phones; now we have smartphones. You might say if you’re using a smartphone, this keto thing, it’s a new technology, you should follow a new technology.
Question: “What happens when the person stops the medicine?”
Answer: I was just talking to my neighbor about this, who’s a nurse practitioner. In the news, someone has said something absurd; it’s a ridiculous statement, which is, you have to stay on it forever. If you get off the medicine, you’re going to gain all the weight back and more. No, come on, calm down. If you are given medicine to get to a goal and then you’re taught how to keep it off, you don’t need the medicine anymore. What’s happening is people are using the medicine and are not being taught how to keep it off, and the weight comes back. If you’re taught how to keep the weight off, you don’t regain the weight. If you’re not taught how to keep the weight off, sure, you go back to the way you were eating, and you’ll regain the weight.
You want to be careful if you have other medical problems. Medicines might cause trouble for the kidneys. Drugs go through what’s called “phase three” studies for FDA approval. Usually, thousands of people are put on the drugs with comparison groups to see if there’s any difference in side effects. Then, there’s something called “phase four marketing results,” where the drug is released and put out into the real world for a while. This is the gamble you’re taking with a drug like this. If you take it for a long period of time, which might be three to six months, is it creating some other change that wasn’t detected in these clinical trials? Is there a side effect or a serious problem that wasn’t found because it was just less common? Things that happen to one in a hundred people will be found in clinical trials. Regarding things that happen to one in a thousand, one in ten thousand, you might not actually see those results in these studies. Once the drug is released, then you follow up and find these issues.
Through training, I realized I don’t want to be the first person to be taking an FDA-approved drug. I wanted it to be out for a little while. That’s just to warn you of the safety aspect of it. For example, there’s a drug called Jardiance, which is being used now for heart failure. There are good clinical trials that show it stops recurrent heart attacks, but it’s at the expense of pretty terrible side effects, like having an infection in the genital area that gets so bad it gives you sepsis, which leads to death.
Medicines can work, but then you have these side effects. In my view, they’re just too strong. Medicines have to work regardless of what people are eating or drinking in terms of weight loss so they have to be super strong and then you buy into the unknown of these medicines.
Question: “Do these medicines have less side effects than Glipizide or other diabetes medicines?”
Answer: I would say the feelings that you get are stronger. Nausea and GI problems. It’s a stronger side effect profile. But not everyone has it; it has to be tolerable enough to get through the clinical trials. I think it’s tolerated well by most people.
Comment: “Some of the appetite suppressants cause heart palpitations for those who are prone to that.”
Answer: Right. Phentermine is the classic upper medicine that might give you palpitations at first. For most people, it’s something you just adjust to and become tolerant of. Ozempic does not seem to cause those, so that might be a reason to choose that over Phentermine. Ozempic might be too strong. Ozempic, which by itself, no matter what you eat, will lead to weight loss, and you combine it with a keto diet, which by itself can lead to weight loss, you may actually get extra side effects with them. I do know some doctors who anecdotally are using them together and they’re doing fine but that’s something you’d want to just be aware of. If you’re having side effects with the combination, it could be that it’s just too darn strong. You would need to do one or the other or do a modified version of a keto diet with it.
Low Carb Denver 2023 Insights
At Low Carb Denver, Amy gave a talk on thyroid, which was fantastic. The committee didn’t want me to have a full talk, so I weaseled my way into being a moderator for one of the sessions, where I got to put in a few two cents here and there. The session that I moderated included a doctor from Miami who’s an expert in the coronary artery calcium score. He had never been to a low carb meeting. I finally got that sense because he was giving the standard doctor cardiology speech. I just had to say, “Well, actually, we see things that doctors don’t normally see because there are a lot of people out here, including my patients in the audience, who don’t eat carbs.” I think he left favorably impressed. He is the one who authored many papers called “The Power of Zero.” What that means is if your coronary artery calcium score is zero, and you’re a carb eater, because remember this is all studied in people who eat carbs, over the next 10 years your likelihood of having a heart attack is super low. It’s not zero, because you’re an American eating carbs, but it’s a lot lower than if your coronary artery calcium score is not zero. That zero score puts you in the gold. I think we can actually do better than that. That’s my hunch; it’s based on the inflammatory markers going down and the reversal of metabolic syndrome.
It was great to have this doctor speak and show all of the updated information. Even if you’re a carb-eater and your LDL is super high, if your calcium score is zero, your risk is really low. He’s been in these guidelines trying to shift and add in this calcium score as a measurement to get people so they don’t need to take statin drugs. It’s been interesting to see. He was very optimistic. He’s a young researcher and reminded me of myself 30 years ago thinking everything would be fixed overnight. But he actually had been on a guideline panel to include the coronary score in some of the cardiac guidelines.
That same morning, we were able to hear from Dave Feldman, a computer scientist, who created the cholesterol code and has a study going on with people who use low-carb keto diets and have a really high LDL level. He presented the first data. They now have recruited a hundred people, and if you got recruited, you would be sent to Los Angeles, and he put in a CT scan machine that looks at the inside of the arteries. It’s called a CT angiogram. The goal is to get 100 people to do a scan and then follow them over the next year, do another scan, and see if there’s any accumulation of damage in the artery from the super high LDL. What was remarkable – now, you can’t write home about it yet – the average length of time of people on a keto diet was about four years, and they had the people who had a super high LDL. The average is about 280 mg/dL (7.2 mmol/L). That’s the average in over four years. Just about everyone – not everyone, but just about everyone had a zero coronary artery calcium score. If LDL was the one and only cause of coronary calcification and coronary blockage, you would expect some of these people to have some serious damage over an average of four years. They didn’t find it. Dave in his usual way said, “I can’t show you my data yet.” What he did is a clever thing. He showed a population study and said the results are very similar to this. So he basically used a different study to let us know what the findings were. Very clever guy. The possibility of having super high LDLs and having it not cause disease is huge. You have doctors and dietitians and grocery store clerks looking at you funny regarding eating eggs and butter and fat and all that; I think it’s going to be fine. It’s the carbs that are doing all the bad things.
There’s a whole subspecialty in internal medicine called the Lipid Association. All they do is obsess about people’s lipids and give them drugs for it. God forbid you could change the lipids by changing the food, but that’s just my subspecialty of internal medicine. They don’t ever ask you about what you eat and drink. They want to diagnose you with things and give you medicines for things. That was the kernel of new data that made the meeting. We were anxiously awaiting what will happen in this study. We need to know what happens when people have super high LDls on a keto diet and they’re not being treated for the LDL elevation.
The Paleo lead speaker – Bill Schindler – who had been on National Geographic, he was a former college professor. He told the story of a Paleo that was designed not to eat carbs. Not in a clinical way but in a historical hunter-gatherer, paleontology way.
There was a nurse practitioner who I met in Salt Lake City last year. She had sent her breast milk to UCLA on her own because she was experimenting with different diets. She showed me her data now of her own breast milk that she sent and how there was more fat in the milk and more calories per ounce when she was doing the keto diet, which makes sense. I’ve had other people tell me doctors who’ve worked with me that if they pump their breast milk, there’s a bigger fat layer if they’re doing a keto diet. I introduced the nurse practitioner with the data to the Paleo speaker. He said, “I’ve thought about this quite a bit, and we use lactose to ferment things. I don’t think the baby absorbs the lactose.” He thinks the microbiome – the bacteria – absorbs the lactose and that the child is probably in ketosis. Then he asks, “Was your baby ever in ketosis?” Sure enough, she had checked with a blood meter, and her ketones matched her kid’s ketones even when breastfeeding. This is anecdotal. For me, back in Indonesia with the Jakarta meeting where I met doctors who talked about “keto babies,” we had hundreds of keto babies. In fact, they’re developing faster than babies that eat carbs. I met with a pediatrician and family doctor there, so I’ve been given the heads up that there may be a signal here.
Dr. Mary Newport, who’s known for giving her husband coconut oil to help her husband’s dementia said, “Yeah, clearly, babies are born in ketosis.” I said, “Well, let’s find it.” I’m trying to get someone to just collect 10 in a row of babies born and and I’m sure they draw blood for other things. Let’s just check some ketones and see because these are all sorts of urban legends that matter.
Watch the full video here.