If you’ve been reading this newsletter for any period of time, you’ll know that I am on team Ozempic.
The incretin mimetics - Ozempic being the most famous of this group of drugs - are the most influential drugs ever developed.1
They are changing our waistlines, healthcare expenditures, purchasing habits, and possibly even impacting addiction.
But not everyone who goes on these drugs has success - some people experience side effects that make them stop the drug and some people don’t seem to lose weight.
So what separates the people who have a good experience from those who don’t?2
The answer to that question has lessons we can apply to many other things in medicine (and probably other things in life as well).
Dr. Alexandra Sowa is a friend and former co-resident of mine who just wrote a book called The Ozempic Revolution about how to be successful on these drugs.
The book is a really useful and practical look at how to succeed on these medications.
Dr. Sowa has a pretty impressive body of experience helping people lose weight in her obesity medicine practice, and so it’s worth taking some of her lessons in this area seriously.
A strong therapeutic relationship is important
Dr. Sowa starts her book by describing the prevalence of weight bias in medicine and how this furthers the struggle with weight that many patients experience.
She also talks about how many doctors give generic and unhelpful recommendations for weight loss that their patients have heard a thousand times before and haven’t been successful.3
And she’s right about that - most doctors don’t have any real training in management of obesity as a chronic disease and many doctors (as well as many people) think that obesity is a personal failure of willpower rather than a chronic disease.4
The book has quite a few patient success stories and testimonials about their success in Dr. Sowa’s practice, feeling like a person dealing with a medical condition rather than a failure of a human who can’t get diet and exercise right.
There’s a lot to that concept: a strong therapeutic relationship makes outcomes better no matter what the treatment is (although it helps when the treatment is effective).
You can look across many areas of medicine to find the benefit of a strong therapeutic relationship - but I’m going to share one outside of traditional medicine to emphasize the point.
Acupuncture seems to improve symptoms in patients suffering with chronic pain from many different etiologies.
But sham acupuncture - just sticking needles in randomly - seems to also improve pain.
And, perhaps even more importantly, importantly, both regular acupuncture and sham acupuncture are superior to not receiving acupuncture.
The therapeutic relationship matters, whether it’s treating obesity, or pain, or more traditional medical ailments.
Medications are only part of treating disease
While the incretin mimetics are truly incredible drugs, for many patients they don’t just work magically, where you take the injections and the weight melts off.
Some people don’t lose weight when they just start taking the drug.
Some people have zero appetite and risk losing significant muscle mass (and thus making their overall health worse) if they aren’t taking action steps to avoid that loss.
Some people have pretty bad side effects from the drugs, but those side effects can be mitigated by titrating the dose up slowly and modifying diet.
And for some people, the drugs work at first but then after they’ve been on the medications for a while, their appetite comes back and it starts to get hard to maintain the positive benefits.
Having a strategy for troubleshooting each of these issues is vital to success.5
In the book, Dr. Sowa talks about the specific ways that she’s helped people troubleshoot many of these problems.
If you don’t have a therapeutic relationship with someone who has experience with these drugs and can help with the pain points, you aren’t maximizing your chances for success.
Frequent touchpoints with the medical system work better in chronic disease
There’s a clinical trial in chronic heart failure called STRONG-HF, where patients with heart failure were randomized to two different strategies: (1) frequent medical touchpoints with rapid initiation of multiple proven medical treatments versus (2) usual care.
The group with the frequent medical touchpoints got on more medications at higher doses more quickly than the usual care group.
They also had better outcomes - less death, higher quality of life, better exercise capacity.
This trial is often cited as proof that rapidly increasing medications is the standard of care in heart failure - and that is certainly one reasonable conclusion.
But another take home message from the study is that people with chronic disease who have frequent touchpoints with the medical system to adjust therapies do better than those who are sporadically seen.
The same is true for obesity.
Just as a therapeutic relationship and thinking about a medication as a part of the treatment (but not the whole treatment) matter a lot, frequent touchpoints matter too.
Dr. Sowa discusses the regular follow up she has with patients to hear about what’s going on with their treatments.
There’s wisdom in the idea that seeing somebody regularly to hear about side effects, adjust medications, and troubleshoot lifestyle issues all make a big difference in dealing with chronic disease.
Remember, obesity is an environmental disease - lasting treatment without relapses involves a permanent environmental adjustment
The final part of the book involves lifestyle strategies for the long haul - exercise tips, meal planning advice, recipes - that emphasize perhaps the most important part of success on Ozempic.
If you don’t change the environment permanently, ultimately treatment is going to be a failure.
Setting yourself up for success by remaking your environment is the only method to keep weight off and avoid the negative health consequences of too much visceral fat.
Dr. Sowa’s tips are one method of accomplishing those lasting environmental changes, but you don’t need to confuse the specifics of her prescription with the big picture framework that it represents.
The specific details matter less than the fact that the changes are made and they are consistent.
I would be remiss if I didn’t note the supplements that she sells on her website.
I want to be clear that while I thought her book is a really helpful and user-friendly guide for success on GLP-1 agonist drugs, I am not endorsing any of the supplement recommendations.6
Supplements aren’t necessary for success, and with any nutritional supplement, I recommend a buyer beware approach - these things need to be rigorously third party tested before you can feel confident in their purity and safety.
And even then, they are probably not necessary for most people.
I think of even the most effective supplements as things that barely move the needle of success for patients.
There’s no “one weird trick” for effortless weight loss and permanent youth that comes in supplement form.
Most of them are not a good use of your money - but every individual case is different, and the only way to make these decisions wisely is to consult with someone who knows the specific details of your medical history and has a strong understanding of how supplements work.
Ultimately, the Ozempic Revolution is a practical guide for success on these drugs
The granular details of how you implement a plan matter.
While sometimes success or failure on Ozempic simply comes down to whether you get coverage for the prescription, it really may matter who is writing the prescription.
The experience, knowledge, and therapeutic relationship of the treating doctor plays a big role in how well these drugs work.
I thought that the book was a really sensible and practical guide to the actual experience of using these drugs that’s written by someone who has a lot of real world experience helping patients successfully lose weight.
But remember that while the principles are universal, the individual details of each successful plan are going to vary from person to person.
Ozempic has the active ingredient semaglutide. This is the same active ingredient as Wegovy, which is just prescribed for the indication of obesity, whereas Ozempic is for diabetes. The other major player in this class of medications is tirzepatide, also known as Mounjaro (when prescribed for diabetes) or Zepbound (when prescribed for weight loss).
My experience is that a small number of people do well just starting the drug and going about their life. But that’s a minority, and most people need a bit more assistance.
It’s true that most doctors have no training in this and very little clinical experience being successful with weight loss interventions. Hopefully this isn’t surprising news.
I am a firm believer that most obesity is an environmental disease. I am not in the camp of the healthy at every size group. But there’s a big difference between thinking that obesity is a chronic disease and thinking that obesity is the fault of the person who is dealing with it. And my own clinical experience would suggest that there are lots of people who are overweight that are really engaged in their health as well as lots of people who are normal body weight who aren’t.
It’s an inefficient exercise to go through each possible side effect and try to troubleshoot it here. The book does this to a certain extent, but often the treatment needs to be individualized because the different issues can be quite idiosyncratic.
There’s a joke that the end stage for every health influencer is either to start your own supplement brand or to start hawking Athletic Greens.